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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604540
Report Date: 04/19/2024
Date Signed: 05/20/2024 01:33:18 PM

Document Has Been Signed on 05/20/2024 01:33 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/
DIRECTOR:		RZOK, NAJAH J.FACILITY TYPE:
735
ADDRESS:2037 SIEGLE DRIVETELEPHONE:
(619) 335-0566
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 6CENSUS: 6DATE:
04/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kevin Jones House ManagerTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management Visit to follow up on events which licensee self reported to the Community Care Licensing San Diego Regional Office (RO). LPA was welcomed by, identified herself to, and discussed the purpose of the visit with House Manager Kevin Jones.

On 04/18/2024, the RO received a LIC624 Unusual Incident Reports regarding Resident #1 (R1) being absent without leave from the facility (AWOL) [see LIC 811 Confidential Names list for a description of R1]. The report said Resident #1 (R1) went to his room after dinner around 6:00 pm. Staff went to his room at 7:30 pm to give him his bedtime meds and discovered that he was not in his room, staff searched the entire house. The house called 911 and the manager went looking for R1. The San Diego Sheriff found him on Skyline Blvd approximately 1 mile away, crying wanting to buy cigarettes. R1 returned home at 8.45 pm and eventually went to bed at 10.30 pm. The facility has records of in services on procedures on resident AWOL. The facility followed the facility policy on resident AWOL.

During today’s visit, LPA briefly toured the facility and performed a welfare check on and interviewed R1. LPA then interviewed facility staff and obtained copies of pertinent facility administrative and care records. No deficiencies were cited during today’s visit.

An exit interview was conducted with Kevin Jones, House Manager, to whom a copy of this report, the Confidential Names list (LIC 811), and the Licensee/Appeal Rights LIC 9058 (03/22) were provided to the Licensee.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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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