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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604540
Report Date: 05/18/2022
Date Signed: 05/18/2022 02:04:29 PM

Document Has Been Signed on 05/18/2022 02:04 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 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: 0DATE:
05/18/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Applicant Najah RzokTIME COMPLETED:
12:10 PM
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Licensing Program Manager (LPM) John Rante, and Licensing Program Analysts (LPAs) Amy Domingo and Kayla Hilario, conducted an announced Pre-Licensing inspection. LPM and LPAs met with Najah Rzok, and we discussed the purpose of the visit.

LPM and LPAs conducted a tour of the facility, both inside and outside. There are no pools on site. The smoke and carbon monoxide alarms were present. Toilets intended for client use were operating as intended, and bathing facilities were observed to be clean and kempt. The windows, blinds and paint throughout the facility, was observed in good condition. Each room intended for client use had the appropriate furniture, bedding and appropriate lighting. Rzok stated there are no firearms stored on the premises.

Hot water temperature was measured in the facility at 117.9 degrees F. The ambient temperature inside the facility was measured with at 74 degrees F. The facility was observed to be clean and kempt with no strong malodors. The refrigerators and freezers were observed to be clean and operational, with an ample amount of food to meet client needs. Cleaning solutions were also properly secured in the garage.

The Component III portion of the application process was completed with Rzok on today's date as well.

The facility does not have an evacuation chair as required by Health and Safety Code Section 1565(f)(1). Pre-Licensing is incomplete with deficiencies to be resolved by June 1, 2022. An exit interview was conducted. The Applicant was provided a hardcopy of this report and their Appeal/Licensee rights (LIC9058 01/16) at the conclusion of the visit.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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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