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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801532
Report Date: 11/22/2022
Date Signed: 11/22/2022 12:57:16 PM


Document Has Been Signed on 11/22/2022 12:57 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:NORMA J'S HOME FOR THE ELDERLY, THEFACILITY NUMBER:
565801532
ADMINISTRATOR:LORETTA LOUISE TIEDEFACILITY TYPE:
740
ADDRESS:142 W. COLUMBIA ROADTELEPHONE:
(818) 422-7667
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Loretta Louise Tiede - LicenseeTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. Upon arrival, LPA met with Administrator Loretta Louise Tiede and explained the reason for the visit.

Facility has (6) resident bedrooms and (3) bathrooms currently occupying (6) residents. (1) bedroom is designated for the staff. Fire extinguishers were observed fully charged and last serviced in October of 2022. Carbon / Smoke detectors were tested and observed to be operation during the time of the visit. All door alarms for exit ways were observed to functional during the visit as well.
 
At approx. 11:00am, LPA toured the facility with Administrator The kitchen appeared to be relatively clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in the top drawer to the left of the sink.

Dining room furniture appeared to be relatively clean and functional at the time of the visit.  At approximately 11:15am, LPA observed (4) residents having lunch at the dining table and (2) residents watching television in the living room. The living room was checked for cleanliness and furniture was checked for functionality during time of visit. Furniture appeared to be relatively clean and functional at this time.

The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Extra linen are kept in a cabinet in the hallway nearest bedroom #1.   LPA observed a sufficient supply of linen and personal hygiene supplies stored at this location as well.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORMA J'S HOME FOR THE ELDERLY, THE
FACILITY NUMBER: 565801532
VISIT DATE: 11/22/2022
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Continued from 809

LPA observed bathrooms to be relatively clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between 105 - 120 degrees Fahrenheit.

Hallway closet by entry door was observed to store coats and other items for facility use. LPA observed a 30 day supply of PPE stored easily in multiple locations throughout the facility. Laundry area was located near bedroom #4. Laundry detergents, cleaning solutions and other toxins were observed to be kept in a locked cabinet inside the garage near the laundry area.

The backyard of the facility has outdoor furniture with a shaded area with sufficient room for activities.  LPA did not observe any obstructions to emergency exits at this time.   The swimming pool was appropriately fenced and observed to be locked and secured. There was a detached storage unit and LPA  observed it to store various holiday decorations. There was a storage room located on the upper left part of the facility. LPA observed it to store extra medical supplies and tools for facility use.

The garage is attached to the home and observed to be locked and secured.  The garage is currently being used as storage for additional  non-perishable and frozen food, supplies, furniture  and old/used equipment. 

 The LPA spoke with Loretta  regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate room #1  as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time.
 
Exit interview conducted. Report issued and sent via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2