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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604535
Report Date: 04/05/2022
Date Signed: 04/05/2022 05:27:22 PM

Document Has Been Signed on 04/05/2022 05:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LLCFACILITY NUMBER:
374604535
ADMINISTRATOR:RZOK, NAJAHFACILITY TYPE:
735
ADDRESS:8475 INNSDALE LANETELEPHONE:
(619) 335-0566
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 4CENSUS: 0DATE:
04/05/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Najah Rzok, ApplicantTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an announced Pre-Licensing visit. LPA was met by Applicant, Najah Rzok, and granted entry into the facility. Ayad George was also present during the visit. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on January 24, 2022, and the facility was approved for 4 ambulatory clients.

During today's visit, LPA, accompanied by Najah Rzok and Ayad George, toured the facility inside and outside and inspected every room. The facility was found to be in good repair with no pathway obstructions. Clients' bedrooms were observed to be clean and contained required furnishings. Toilets were found to be in working order. Facility temperature was 70 degrees F during the visit. Hot water temperature in client bathrooms measured at 117.9 and 115.5 degrees F. Hazardous and/or toxic chemicals were stored and secured in locked areas that are inaccessible to clients. There were locked cabinets for storage of medications. Client and staff records were stored confidentially. There was a first aid kit present in the facility. Activities and sufficient space in which to conduct activities were present. Fire extinguishers were observed in the facility. Hard-wired smoke and carbon monoxide detectors were present and were recently inspected by the local fire authority. No pools or bodies of water were observed near or on the premises. According to the applicant, no firearms and/or ammunition were present or will be stored in the facility. Perishable and non-perishable food items were present and appropriately stored in the facility. Postings were observed in a visible area of the facility. LPA conducted Component III with the applicants. The topics discussed were continuing operation requirements, record keeping/reporting, and physical plant compliance.

Pre-Licensing is complete, and no deficiencies were observed during the visit. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted, and a copy of this report was provided to Applicant Najah Rzok, via email, following the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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