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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604540
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:39:13 PM

Unsubstantiated


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
01/09/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20250109144125
FACILITY NAME:NOR LIVING 5 LLCFACILITY NUMBER:
374604540
ADMINISTRATOR:RZOK, NAJAH J.FACILITY TYPE:
735
ADDRESS:2037 SIEGLE DRIVETELEPHONE:
(619) 335-0566
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:6CENSUS: 6DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
07:35 AM
MET WITH:House Manager Kevin JohnsonTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Lack of supervision
Licensee did not maintain first aid kit
Staff records were not available for review
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Amy Rodgers and Angelica Boyles conducted an unannounced complaint visit to the facility to open a complaint on the above-mentioned allegations. LPAs gained access to the facility, identified themselves, and met with House Manager, Kevin Jones to discuss the purpose of the visit.

The Department’s investigation consisted of review of a staff files, facility files, interviews with staff, interviews with clients as well as interviews with outside sources.

[Continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
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 2
Control Number 08-AS-20250109144125
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: NOR LIVING 5 LLC
FACILITY NUMBER: 374604540
VISIT DATE: 01/15/2025
NARRATIVE
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[continued from 9099]

It was alleged that due to lack of supervision the licensee did not meet overnight coverage for clients in care, specially the night shift time sheets did not match the night shift schedule. It was reported that, based upon the needs of the clients in care, during the weeks of 12/15/2024 through 1/4/2025, the licensee was required to have a one awake staff working on the PM shift. Interview conducted, review of outside source records, as well a review of facility records reflected that on 12/15/2024 through 1/4/2025, from 10pm to 6am there was one staff present and awake at the facility.

It was alleged that full and complete staff records were not available for review during the quality control inspection of the facility by vendor, San Diego Regional Center. Specifically training documentation were not present at the time of the San Diego Regional Center quality control audit. Based on interviews and a review of available training records, all currently employed staff members were found to meet the training requirements from Title 22 of the California Code of Regulations. All personnel employed by the facility were verified to have received on-the-job training upon hiring orientation. Staff interviews revealed feeling competent in their job duties and consistently identified facility protocols regarding the various responsibilities performed for their role. Although the records were not present for additional CEU/competency training for Title 17, an outside source did not express any concerns regarding staff competency when providing care to clients. During the unannounced facility visits LPAs observed staff assisting clients. LPAs did not observe any staff performing a task in a way that indicated lack of competency or training.

It was alleged that Licensee did not maintain first aid kit, more specifically the first aid kit contained expired supplies. Observations revealed the facility did have a first aid kit on site readily available in a central location. The supplies contained in the first aide kit were found to meet the requirements from Title 22 of the California Code of Regulations. No supplies were identified as expired.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.



An exit interview was conducted with House manager Kevin Jones, whose signature below confirms receipt of a copy of this report..
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2