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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604431
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:27:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2023 and conducted by Evaluator Renita Hall
COMPLAINT CONTROL NUMBER: 08-AS-20230613084338
FACILITY NAME:SENIOR LIVING NORWOODS HACIENDA IIIFACILITY NUMBER:
374604431
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:9414 GROSSMONT BLVDTELEPHONE:
(818) 284-2502
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:6CENSUS: 4DATE:
11/07/2023
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Wendy Gomez, CaregiverTIME COMPLETED:
02:27 PM
ALLEGATION(S):
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Facility did not issue required refund to resident's authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by Wendy Gomez, Caregiver. LPA identified herself and disclosed the purpose of the visit and shared findings with Wendy Gomez, Caregiver.

One June 13, 2023 the Department received a complaint that the Power of Attorney (POA) had not received a refund from the facility after the death of Resident 1 (R1) back in April 2023. On June 2, 2023 and June 6, 2023 the POA requested an update on the refund which had passed the 90 days that the Administrator had verbally told the POA would be refunded. However, the POA did not received an update from the Administrator. The Department reached out to the Administrator who stated that a refund had been given in the month of May 2023 by way of check. The POA had never received the refund and the Administrator could not provide proof that the refund/check had been cashed by the POA. The Administrator was asked by the Department to provide records that documented a refund was given.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 08-AS-20230613084338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SENIOR LIVING NORWOODS HACIENDA III
FACILITY NUMBER: 374604431
VISIT DATE: 11/07/2023
NARRATIVE
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Review of records showed on the LIC401 monthly income and expenses. However, the LIC401 did not show a refund was given back to R1's Power of Attorney (POA). The regulations for refunds after a death of a resident is 15 days. On August 1, 2023 the POA had received the refund.

Based on the evidence obtained during the complaint investigation, the allegation of staff Facility did not issue required refund to resident's authorized representative was found to be SUBSTANTIATED, as there is a preponderance of evidence to prove the alleged violation occurred. However, the refund was finally given on August 1, 2023.

An exit interview was conducted; a copy of this report along with Licensee Appeal Rights LIC 9058 (REV 3/22) were provided to the Facility Executive Director and their signature confirms receipt of these document
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230613084338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SENIOR LIVING NORWOODS HACIENDA III
FACILITY NUMBER: 374604431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
HSC
87507(c)
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(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility or entity contractually responsible to.... the resident’s estate, within 15 days after the personal property is removed.
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1. Review and update the facility's policies and procedures regarding refunds of fees paid in advance after a resident's personal property has been removed from the facility by November 27, 2023.
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This requirement was not met as evidenced by: Based upon interviews, records reviewed. The licensee did not provide refund timely to the responsible party after the death of resident.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3