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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604540
Report Date: 05/23/2022
Date Signed: 05/24/2022 08:33:44 AM

Document Has Been Signed on 05/24/2022 08:33 AM - 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:
05/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Ayad GeorgeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst, Kayla Hilario, conducted an announced Pre-Licensing inspection. LPA met with Ayad George, identified herself and discussed the purpose of the visit.

The facility owners have purchased an evacuation chair as required by Health and Safety Code Section 1565(f)(1). Pre-Licensing is complete with no deficiencies. An exit interview was conducted with Ayad Geroge. A copy of this report and Appeal/Licensee rights (LIC9058 01/16) were provided via hardcopy at the conclusion of the visit.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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