565801532-10-30-2023-29-AS-ECAS-CX4UWV-20231030155723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801532
Report Date: 10/30/2023
Date Signed: 10/30/2023 03:57:41 PM

Document Has Been Signed on 10/30/2023 03:57 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, THE		FACILITY NUMBER:	565801532
ADMINISTRATOR:	LORETTA LOUISE TIEDE		FACILITY TYPE:	740
ADDRESS:	142 W. COLUMBIA ROAD		TELEPHONE:	(818) 422-7667
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	10/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Loretta Tiede		TIME COMPLETED:	04:05 PM

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:30 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Loretta Tiede arrived shortly thereafter.

The LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 regulations.

BEDROOMS/BATHROOMS: Beginning at 11:00 a.m. the LPA inspected the bedroom and bathroom areas. Bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are five designated resident rooms, one shared and four private resident rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured between at 116.9 and 117.6 degrees Fahrenheit.

KITCHEN: The LPA inspected the kitchen/food service area, knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested at 11:25 a.m. and operational at the time of the visit. The two fire extinguishers were fully charged and last serviced Oct 17, 2023. The LPA observed required postings throughout the common spaces.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORMA J'S HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 565801532
	VISIT DATE: 10/30/2023

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate that is single latched. There is a gated pool in the backyard that was locked and inaccessible a the time of the visit. Exits are free of obstructions. The garage is attached, locked and inaccessible with an additional refrigerator with perishable food. Cleaning supplies and disinfectants are kept in locked in the garage. There is a laundry closet located in the hallway where the washer and dryer are held laundry supplies are kept locked in a locked cabinet. The facility keeps a sufficient amount of emergency food supplies and water in the garage.

INFECTION CONTROL: 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 a single isolation room if the facility has a confirmed case of COVID-19.

RECORDS: Residents’ records review began at 12:15 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Due to time constraints, the LPA will return at a later date to complete the inspection.

The LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Liability Insurance
- Disaster Plan

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC809 (FAS) - (06/04)

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