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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850328
Report Date: 01/15/2025
Date Signed: 01/15/2025 06:16:37 PM

Document Has Been Signed on 01/15/2025 06:16 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 III, THEFACILITY NUMBER:
565850328
ADMINISTRATOR/
DIRECTOR:
TIEDE, LORETTA LOUISEFACILITY TYPE:
740
ADDRESS:118 W COLUMBIA RDTELEPHONE:
(805) 870-4886
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Loreta Louise TiedeTIME VISIT/
INSPECTION COMPLETED:
03:45 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 Administrator. Reason for visit was stated. LPA was informed and observed the home was experiencing a power outage during the visit. Administrator stated that the power was shut off due to the winds (shut off estimated for 8hrs). LPA and Administrator discussed emergency disaster plan, and best practices. Facility has a generator, for needed power during outage. Residents will relocate with family if needed.
At approximately 2:30p.m., the LPA conducted a tour of the physical plant with Administrator and staff to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility consists of five (5) client bedrooms, four (4) bathrooms in the main house; one bedroom and one bath in the back house. The LPA observed fire extinguisher, which was fully charged and last serviced 10/15/2024. All smoke alarms and carbon monoxide detectors were tested and operable. Required postings observed on the wall. Administrator will get a poster size of the state complaint poster. BEDROOMS/ BATHROOMS: LPA inspected the bedroom and bathroom areas. Bedrooms were furnished appropriately with clean linens, appropriate furnishings. 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 is within required range (105-120*f). 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 (76 degrees). Smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. OUTDOOR AREA: The backyard has a outdoor area equipped with furniture for resident use. 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. Due to time constraints annual inspection will continue on a later date to review staff, residents and medication records. No deficiencies issued during todays visit. Exit conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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