565802455-8-29-2024-29-AS-ZCHN-D8LPLZ-20240829112534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802455
Report Date: 08/27/2024
Date Signed: 08/29/2024 11:25:56 AM

Document Has Been Signed on 08/29/2024 11:25 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 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: 5	DATE:	08/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Loretta Tiede & Robin Douglas		TIME COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA was greeted by staff and informed them of the reason for the visit. Administrator Loretta Tiede was contacted. Mrs. Tiede stated she is with a resident at an appointment and stated that the lead staff Robin Douglas will assist LPA with the Annual inspection.

At approximately 11am, 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: LPA inspected the bedroom and bathroom areas. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six designated 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 115.7 and 116.9 degrees Fahrenheit. 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 76 degrees. Smoke detector(s) and carbon monoxide detector were tested at 11:25 am and operational at the time of the visit. The fire extinguisher was fully charged and last serviced Oct 11, 2023. The LPA observed required postings throughout the common spaces. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There is a side gate for resident use and is single latched. No bodies of water noted and exits are free of obstructions. The garage is attached, locked and inaccessible. Garage is where the washer and dryer are held, including additional refrigerator with perishable food items. Cleaning supplies and disinfectants are kept in locked in the garage. The facility keeps a sufficient amount of emergency food supplies and water in the garage.

RECORDS: Residents’ records review began at 11:45 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Staff records review began at approximately 1:15pm. (Continue to LIC809c)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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 II, THE	FACILITY NUMBER: 565802455
	VISIT DATE: 08/27/2024

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Staff records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Four staff files including Administrator's file reviewed and observed to be in order.

MEDICATIONS: Medications review began at 3p.m.; medications are centrally stored and locked in a filing cabinet in the kitchen dining room. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. LPA observed no PRN authorization letter on file for residents with PRN medication. PRN log records observed on file. No other issues observed during the medication review.

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.

The LPAs obtained the following documents:

- LIC500 Personnel Report
- Liability Insurance
- Updated Disaster Plan

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

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