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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604540
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:35:42 PM

Document Has Been Signed on 07/28/2023 02:35 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
SAN DIEGO RO, 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: 6DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Kevin JonesTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Direct Support Professional (DSP) Lucky Morales, to whom LPA discussed the purpose of the visit. House Manager Kevin Jones arrived at the facility shortly.

According to the facility’s license, the facility has a maximum capacity of six (6) ambulatory clients. During today’s inspection, one (1) client was in care. Five (5) clients were out in day programs.

LPA, accompanied by DSP Morales, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant at 69 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 106.2 F, bathroom #1 sink was 105 F, bathroom #2 sink was 113.4 F, and bathroom #3 sink was 115.5 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/28/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per DSP Morales, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers (2) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. The House Manager presented proof of current/active business liability insurance.

LPA interviewed staff present. Client present is non-verbal and could not carry on a conversation. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Files reviewed were missing several required documents. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). A Plan of Correction was jointly developed with House Manager Jones.

An exit interview was conducted with House Manager Jones, to whom copies of this report, the LIC 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/28/2023 02:35 PM - It Cannot Be Edited


Created By: Riza Gloria Alvarez On 07/28/2023 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NOR LIVING 5 LLC
FACILITY NUMBER: 374604540

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in five (5) out of six (6) facility staff, which poses a potential health risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee will submit to CCL completed health screening reports of five (5) facility staff.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four (4) out of six (6) facility staff, which poses a potential health risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee will submit to CCL TB test documents of four (4) facility staff.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Denise Powell
LICENSING EVALUATOR NAME:Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/28/2023 02:35 PM - It Cannot Be Edited


Created By: Riza Gloria Alvarez On 07/28/2023 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NOR LIVING 5 LLC
FACILITY NUMBER: 374604540

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of six (6) facility staff, which poses potential health and safety risks to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee will submit to CCL proof of completed first aid training of three (3) facility staff.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two (2) out of six (6) clients in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee will submit completed admission agreements for two (2) clients.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Denise Powell
LICENSING EVALUATOR NAME:Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/28/2023 02:35 PM - It Cannot Be Edited


Created By: Riza Gloria Alvarez On 07/28/2023 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NOR LIVING 5 LLC
FACILITY NUMBER: 374604540

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (1) out of six (6) clients in care, which poses a potential health risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee will submit to CCL the completed written medical assessment specified in Section 80069 for one (1) client.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Denise Powell
LICENSING EVALUATOR NAME:Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
Page: 5 of 5