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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801532
Report Date: 02/16/2023
Date Signed: 02/16/2023 11:29:51 AM

Document Has Been Signed on 02/16/2023 11:29 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
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: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Susana VincecruzTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20220325091634). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint # 29-AS-20220325091634, the following deficiency was observed: On 01/28/2022, Resident #1 (R1) was admitted to the facility. The Physician’s Report, dated 01/28/2022, lists R1 has having no capacity for self-care which is a prohibited health condition. The licensee did not submit an exception request to admit and retain a resident with a prohibited health condition.

Exit Interview. Citation issued. Appeal Rights discussed. Report was reviewed with staff Susana and a copy of report was given.
Desaree PereraTELEPHONE: (818) 596-4347
Martha ArroyoTELEPHONE: (818) 421-6459
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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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Document Has Been Signed on 02/16/2023 11:29 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
02/16/2023
Section Cited
CCR
87615(a)(5)

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Persons who require health services for or have a health condition…shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by:
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Administrator will submit memo of understanding that you have read and will comply with Title 22 Regulation 87615 Prohibited Health Conditions and 87616 Exceptions for Health Conditions and submit to CCL by 2/17/2023.
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Based on record review, the licensee admitted and retained R1 who had no capacity for self-care, which posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree PereraTELEPHONE: (818) 596-4347
Martha ArroyoTELEPHONE: (818) 421-6459

DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023

LIC809 (FAS) - (06/04)
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