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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850328
Report Date: 01/19/2024
Date Signed: 01/19/2024 04:18:33 PM

Document Has Been Signed on 01/19/2024 04:18 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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: 6DATE:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Loretta Louise TiedeTIME COMPLETED:
04:20 PM
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At 2:30 p.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Licensee Loretta Tiede arrived shortly.

At 2:40 p.m. the LPA conducted a tour of the physical plant with the Licensee to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms, and five (5) restrooms. The LPA observed two (2) fire extinguisher which were fully charged and last services on 10/17/2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents.

Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding.

Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. The water temperature in resident’s restroom in bedroom #2 was measured at 116.9 degrees Fahrenheit. The hot water measured was within the required limit of 105-120 degrees Fahrenheit.

Report will continue LIC809-C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORMA J'S HOME FOR THE ELDERLY III, THE
FACILITY NUMBER: 565850328
VISIT DATE: 01/19/2024
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Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. There were no obstructions and/or tripping hazards throughout the facility.

The garage: The LPA observed the garage where additional supplies and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in the garage. The garage is locked.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises.

Interviews: The LPA conducted one (1) resident Interview. No immediate concerns were voiced.

Record Review: A review of facility files was initiated. However, due to time constraints the LPA will return at a later time to complete the annual.

Exit interview conducted and copy of the report provided Licensee Loretta Tiede
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC809 (FAS) - (06/04)
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