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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850328
Report Date: 04/06/2023
Date Signed: 04/06/2023 03:52:03 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:
04/06/2023
UNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Loretta TiedeTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Licensee/Administrator was not acting in good character with outside agency and interfered with their duties
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Elsie Campos conducted a subsequent visit to deliver the findings for the above allegation. Upon arrival, the LPA met with staff Robin Douglas and explained the reason for the visit. Administrator, Loretta Tiede arrived shortly thereafter.

On 3/15/2023,the LPA conducted an initial 10 day complaint visit. 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: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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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: 04/06/2023
NARRATIVE
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Regarding allegation: Licensee/Administrator was not acting in good character with outside agency and interfered with their duties.

The complainant alleged that the Administrator was speaking loudly and was not acting in good character with an outside agency and asking them to leave the facility which interfered with their duties. Interviews with residents denied claims that the Administrator was acting out of character. Residents confirmed that they were bothered by the outside agency representative who was disturbing their peace by not listening to the Administrator who wanted to take the representative outside to clarify the reason for their visit. Staff interviews confirmed that the Administrator was not acting out of character and was simply attempting to get clarification on the representative’s business at the facility. Interviews with staff confirmed that the Administrator is a naturally loud person with no negative tone or ill intentions. Interview with outside agency representative indicated that that they had informed staff of the reason for the visit and therefore did not find reason to explain their visit to the Administrator as they are not required too. Staff confirmed that the Administrator had been speaking loudly as they were helping a resident locate a phone when the representative arrived however, this is only the tone of their voice and there was nothing unusual about the Administrators character or behavior which is positively received by all staff and residents at the facility. Residents further expressed positive experiences at this facility and denied otherwise that the Administrator did not act in good character with an outside agency.

Based on the information obtained, there is insufficient evidence to support the claim that Licensee/Administrator was not acting in good character with outside agency and interfered with their duties. While this allegation or may or may not have happened. This 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: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
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