<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850328
Report Date: 03/15/2023
Date Signed: 03/15/2023 04:38:58 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2023 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20230314135749
FACILITY NAME:NORMA J'S HOME FOR THE ELDERLY III, THEFACILITY NUMBER:
565850328
ADMINISTRATOR:TIEDE, LORETTA LOUISEFACILITY TYPE:
740
ADDRESS:118 W COLUMBIA RDTELEPHONE:
(805) 870-4886
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Loretta TiedeTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Cleaning supplies are not properly stored
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Elsie Campos conducted an unannounced initial 10-day complaint visit for the above allegations. Upon arrival, the LPA met with staff Robin Douglas and explained the reason for the visit. Administrator, Loretta Tiede arrived shortly thereafter.

During today's inspection, the LPA observed the kitchen at 2:38 p.m.,conducted a facility tour at 2:56 p.m. to ensure there are no health and safety concerns. Interviewed staff at 2:43 p.m., and 2:52 p.m. and interviewed a resident at 3:35 p.m.

**Continued on LIC 9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20230314135749
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III, THE
FACILITY NUMBER: 565850328
VISIT DATE: 03/15/2023
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
Regarding the allegation: Cleaning supplies are not properly stored

It was alleged that a kitchen cabinet under the sink was observed to be open with cleaning supplies accessible. Interviews with staff revealed that at the time of the observation staff were actively in the kitchen cleaning, repairing a garbage disposal and preparing snacks, as residents were sitting at the table convening with one another. During today’s visit, the LPA conducted a physical plant tour of all the resident rooms and common spaces. Areas observed included the common areas, dining room, kitchen, garage, resident bedrooms, bathrooms, patio and exterior of the facility. During today's visit, areas were observed to be appropriately cleaned and all cleaning supplies were observed to be properly stored. The kitchen cabinet that is used to store cleaning supplies was locked and was not observed to be in disrepair. The LPA additionally attempted to open the cabinet and was unable to do so. Based on interviews, the Department does not have sufficient evidence to support the allegation that cleaning supplies are not properly stored, while this allegation may or may not have happened the allegation is deemed Unsubstantiated at this time.

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

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3