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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801532
Report Date: 11/13/2023
Date Signed: 11/13/2023 03:10:28 PM

Document Has Been Signed on 11/13/2023 03:10 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, THEFACILITY NUMBER:
565801532
ADMINISTRATOR:LORETTA LOUISE TIEDEFACILITY TYPE:
740
ADDRESS:142 W. COLUMBIA ROADTELEPHONE:
(818) 422-7667
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
11/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Loretta Tiede/Robin DouglasTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a continuation to a required annual visit at 1:25 p.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Loretta Tiede arrived shortly thereafter.

MEDICATIONS: Medications review began at 1:50 p.m.; medications are centrally stored and locked in a cabinet in the kitchen office nook. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.


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: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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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