374604540-4-5-2023-08-AS-DNGN-CQLTCD-20230405143634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604540
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:36:39 PM

Document Has Been Signed on 04/05/2023 02:36 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 LLC		FACILITY NUMBER:	374604540
ADMINISTRATOR:	RZOK, NAJAH J.		FACILITY TYPE:	735
ADDRESS:	2037 SIEGLE DRIVE		TELEPHONE:	(619) 335-0566
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY: 6		CENSUS: 5	DATE:	04/05/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	House Manager Shanta Haines & DSP Lucky Morales		TIME COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit DSP/Caregiver Lucky Morales. LPA then met with House Manager Shanta Haines, who arrived later during the visit.

Today's visit was in response to a Special Incident Report (SIR) which licensee self-submitted to the CCLD San Diego Regional Office (RO) on 04-03-2023. Per the SIR: on 03-31-2023, Client #1 (C1) had an AWOL (absent without leave) incident, and police were assisting in the search. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] During today’s visit, LPA briefly toured the facility and performed a welfare check on the clients who were present, to include C1 (who since returned to the facility). LPA also interviewed pertinent staff and reviewed relevant care records.

According to C1’s most recent LIC602 Physician’s Report, their doctor deemed them able to safely leave the facility unassisted. However, per C1’s LIC625 Appraisal/Needs and Services Plan, they were not able to safely leave the facility unassisted, had a history of eloping, and a main care objective was reducing such events. C1’s latest Individual Program Plan (IPP) from San Diego Regional Center (SDRC) essentially stated that to mitigate C1's AWOL behavior, C1 was to “alert staff” whenever they felt “the need to escape or leave an area” and that facility staff were to “identify antecedents to elopement behavior and to intervene when those antecedents are observed.”

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NOR LIVING 5 LLC	FACILITY NUMBER: 374604540
	VISIT DATE: 04/05/2023

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[CONTINUED FROM LIC 809]

Records and interviews revealed: on 03-31-2023 around 5:00 PM, C1 approached Staff #1 (S1) asking to be taken to Walmart, but S1 was in middle of passing medications to clients. C1 quickly became upset and yelled before leaving the facility on foot. Staff #2 (S2) witnessed C1 leave and followed them on foot, until they could no longer keep up. Staff #3 (S3) was summoned and arrived at the facility help locate C1, unsuccessfully. Facility staff phoned law enforcement around 5:45 PM, phoned C1’s responsible party around 6:30 PM, and phoned SDRC around 8:30 PM. The next morning (04-01-2023), C1 returned to the facility on foot. C1 had a blackened right eye, swelling/bleeding near their cheek/mouth, abrasions on their legs, and torn clothing. C1 told facility staff and LPA that they had been involved in a physical altercation with a stranger out in the community during the AWOL. Facility staff cross-reported C1’s narrative and injuries to police and called 911 to arrange for C1 to be medically evaluated, but C1 was discharged from the hospital later the same day.

At the present time, there does not exist a preponderance of evidence showing that facility staff did not meet C1’s observation and supervision needs, or that license was directly culpable for C1’s AWOL or ensuing injuries. However, licensee did not have an Absentee Notification Plan for C1, or equivalent written document meeting the requirements of California Health and Safety Code Section 1507.15. LPA also observed two (2) required fire extinguishers that had not been professionally inspected/serviced within the last 12 months.

Deficiencies are cited per California Code of Regulations, Title 22, and California Health and Safety Code (refer to the attached LIC 809-D). The Department has determined one of these violations resulted in the facility not complying with its approved Fire Clearance from the local fire authority. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC 421IM.

Plans of Correction were jointly developed with the licensee. An exit interview was conducted with Haines, to whom a copy of this report, the LIC 809-D, the LIC 421IM, the LIC811 Confidential Names List, and the and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/05/2023 02:36 PM - It Cannot Be Edited

Created By: Dang Nguyen On 04/05/2023 at 01:46 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: 04/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/06/2023 Section Cited CCR 80020(a)	1 2 3 4 5 6 7	80020 Fire Clearance: “(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshall.”	1 2 3 4 5 6 7	Licensee agreed to call a vendor to make an appointment to service its fire extinguishers, and to E-mail LPA the anticipated service date before the POC due date. Upon completion of service, Licensee agreed to E-mail LPA photos of the updated service tags for each of the facility's fire extinguishers.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on LPA observation, licensee did not maintain ongoing compliance with its prior-approved fire clearance, which posed an immediate safety risk to persons in care.	8 9 10 11 12 13 14
Type B 05/05/2023 Section Cited HSC1507.14	1 2 3 4 5 6 7	1507.14 Absentee notification plan for missing residents or participants: “Every community care facility that provides adult residential care…for the purpose of addressing issues that arise when an adult or an adult day program participant is missing from the facility, develop and comply with an absentee notification plan…”	1 2 3 4 5 6 7	Licensee agreed to: a) write an Absentee Notifcation Plan/Policy (meeting the requirements of H&S Code 1507.14); b) to add a copy of it to the care charts of C1, C2, C3, C4, and C5, and c) to train its staff on the Plan/Policy. Licensee agreed to send LPA a copy of the Plan/Policy and the training sign-in sheet by the POC due date.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on records and interviews, the licensee did develop and comply with an absentee notification plan for 5 of 5 clients (C1, C2, C3, C4, and C5), which posed a potential safety risk to persons in care.	8 9 10 11 12 13 14

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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC809 (FAS) - (06/04)

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