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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604535
Report Date: 04/04/2024
Date Signed: 04/04/2024 11:50:33 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/12/2024 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20240312164733
FACILITY NAME:NOR LIVING 3 LLCFACILITY NUMBER:
374604535
ADMINISTRATOR:RZOK, NAJAHFACILITY TYPE:
735
ADDRESS:8475 INNSDALE LANETELEPHONE:
(619) 335-0566
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:4CENSUS: 3DATE:
04/04/2024
UNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:House Manager Sony KareemTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee's staff yelled at client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent Complaint Visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with House Manager Sony Kareem.

The Complainant alleged that Licensee’s staff, Staff #1 (S1), yelled at Client #1 (C1). [See LIC811 Confidential Names List for a description of S1.] CCLD’s investigation involved an unannounced facility tour/welfare check, finding all clients in care were safe/uninjured. LPA collected copies of and reviewed pertinent care records. LPA also interviewed 3 of 3 clients in care (to include C1), 6 of 6 direct care staff (to include S1), multiple facility managers, and an outside source. Per Licensee, during the time frame of the complaint allegations, the facility’s cameras were not yet active. The Department’s investigation did not involve review of camera footage.

[CONTINUED ON LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
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-20240312164733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: NOR LIVING 3 LLC
FACILITY NUMBER: 374604535
VISIT DATE: 04/04/2024
NARRATIVE
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[CONTINUED FROM LIC 9099] According to C1’s LIC602 Physician’s Report (dated 05/08/2023): C1 had bipolar disorder and anxiety disorder, but they did not experience memory impairment or hallucinations. Their doctor determined that C1 was not confused, able to follow instructions, and able to communicate their needs. C1 demonstrated to LPA that they were oriented to person, place, and time and able to differentiate truth from lie. However, both internal and external interviews and care records widely showed that C1 themselves frequently chastised and/or yelled at facility staff and made false statements. These latter factors affected the weight CCLD assigned to independent testimony from C1.

Per interview of C1: During a staff shift change meeting, S1 raised their voice and spoke towards them “in a harsh way,” blaming C1’s earlier challenging behaviors for causing stress for a pregnant coworker of S1.

Per interview of S1: They admitted to recently conducting shift change meetings (with the incoming staff relieving them) in a common area of the facility where C1 overheard them. S1 said they recognized this was a mistake and they now perform shift change meetings in a private area. S1 denied raising their voice at or speaking harshly towards C1.

Per interview of Staff #2 (S2): During the complaint time period, S2 participated in a shift change meeting in which S1 spoke to them about C1’s behaviors and how they affected a coworker’s pregnancy. During the meeting, S1 was upset and raised their voice increasingly louder, wanting C1 to overhear what was being said. At one point, S1 turned towards and shook their finger at C1 to chastise them. Soon after, C1 was on the verge of tears. S2 spoke one-on-one with C1 to comfort them.

After speaking to all clients and staff of the facility, LPA did not encounter allegations or evidence of S1 or other staff raising their voice at other clients in care.

Based on interviews, a preponderance of evidence exists to show that S1 yelled at C1 (in a way that did not uphold Clients’ Personal Rights) on at least one occasion. The allegation is therefore Substantiated. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Kareem, to whom a copy of this report, the LIC 9099-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240312164733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NOR LIVING 3 LLC
FACILITY NUMBER: 374604535
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2024
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights: “(a)…each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.” This requirement was not met, as evidenced by:
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Licensee agreed to retrain all staff on Clients’ Personal Rights (as articulated in form LIC613), and to submit the training sign-in sheet to LPA, by the POC due date.
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Based on client and staff interviews: Licensee’s staff (S1) did not accord 1 of 3 clients (C1) dignity, which posed a potential personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
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