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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604540
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:40:58 AM

Document Has Been Signed on 06/14/2024 11:40 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
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: DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:House Manager Kevin JohnsonTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Amy Rodgers 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) Jerrion Maulope 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, Five (5) clients were out in day programs.

LPA, accompanied by House Manager Jones, 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 72 F. Hot water temperature at taps accessible to clients were all compliant..

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: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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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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: 06/14/2024
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per House Manger Jones 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 and surety bond

LPA interviewed staff. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

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

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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