565802455-8-9-2022-29-AS-MARO-CH5UAB-20220809152429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802455
Report Date: 08/09/2022
Date Signed: 08/09/2022 03:25:01 PM

Document Has Been Signed on 08/09/2022 03:25 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 II, THE		FACILITY NUMBER:	565802455
ADMINISTRATOR:	TIEDE, LORETTA LOUISE		FACILITY TYPE:	740
ADDRESS:	73 MARIMAR ST		TELEPHONE:	(805) 852-5511
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	08/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Loretta Tiede		TIME COMPLETED:	03:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 1:15 p.m. The last Annual conducted at this facility was on 7/18/2019. Upon arrival, the LPA was scanned and greeted at the door by Staff, Robin. The Administrator, Loretta Tiede was present at the facility and was explained the reason for the visit. Entrance interview.

At 1:22 p.m., the LPA along with the Administrator began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The LPA observed one (1) refrigerator with a sufficient supply of perishable and non-perishable food. The LPA observed knives and sharps in a drawer locked and inaccessible to residents at the time of visit.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed in the restrooms. Bathrooms were measured for hot water, at 1:45 p.m. the first bathroom measured at 106 degrees Fahrenheit, at 1:49 p.m., the second bathroom measured at 110.6 degrees Fahrenheit, and at 1:51 p.m., the third bathroom measured at 110.7 degrees Fahrenheit. …Report Continued on LIC 809C…

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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 II, THE	FACILITY NUMBER: 565802455
	VISIT DATE: 08/09/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

...Report Continued from LIC 809...

GARAGE AND BACKYARD: The garage is attached to the house and locked at all times. Cleaning supplies and chemicals are stored and inaccessible to residents in care. There is one (1) additional refrigerator in the garage with perishable items in good condition. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. At 1:39 p.m., the LPA observed five (5) residents in the living room watching television.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and CDSS PINS. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings at the time of visit. If needed, the facility has the capacity to self-isolate residents if the facility has a confirmed case of COVID-19.

The LPA and Administrator discussed staff vaccination requirements. All staff are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted. No citations issued. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2