The Norma J's Home for the Elderly

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian conducted a required annual visit. Upon arrival, LPA met with staff (2). Reason for the visit was stated. Facility manager Robin Douglas contacted Administrator Loreta T. who arrived during the inspection. At approximately 10:50 a.m.,LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Following was observed: KITCHEN: Knives and sharps were observed in a locked drawer. Cleaning supplies were observed locked under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 105.9 degrees Fahrenheit. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At approximately 11:45, smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 10/26/2025. The LPA observed required postings throughout the common space. Emergency disaster drills conducted quarterly as per regulation; the last drill was conducted on 09/05/2025. Activities were observed in the common areas. Laundry detergent was observed in a locked cabinet above the washer and dryer. RESTROOMS: There are three (3) restrooms for resident use. Bathrooms observed in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 105 degrees Fahrenheit; the second bathroom measured at 108.7 degrees Fahrenheit; and the third bathroom measured 110.2 degrees Fahrenheit. BEDDROOMS: There are 6 (six) total bedrooms in the facility; one (1) is designated as a shared room, four (4) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. GARAGE/BACKYARD: The garage was locked and inaccessible to residents at the time of the visit. There is an additional refrigerator with perishable food, in good condition. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear of any obstructions. There is a side gate that is single latched. LPA observed a gated pool in the backyard that was locked and inaccessible at the time of the visit. RECORDS: LPA reviewed Resident and Staff Records at approximately 1:30 p.m. Six (6) resident (R) files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, current needs and services plan, hospice binder. No hospice care plan observed for the current residents (R1 R4, R5, R6) on hospice. Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. MEDICATIONS: Medications review began at approximately 3p.m. The medications are locked in a cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are labeled and checked for expiration dates. Medications appeared to be given as prescribed at the time of the visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 19, 2025

The state marks this report as 11 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff sexually abused resident in care Staff forced resident to take medications

Licensing Program Analyst (LPA) Zabel Chochian initiated a subsequent complaint visit to issue finding for the above allegations. Upon arrival, the LPA with staff Robin Douglas at approximately 1p.m. and reason for the visit was explained. Administrator Loretta L. Tiede was contacted and the investigation finding was discussed. . On 01/21/2025, the Department received a complaint which alleged that resident #1 (R1) was forced to take a medication by Staff #1 (S1) before going to bed on 01/17/2025. It was also reported that R1 was forced to take an unknown medication numerous times while under the care of the facility. In addition, it was alleged that Staff #1 (S1) sexually abused R1 on 01/18/2025. It was reported that R1 felt someone on top of them, pushing down on R1’s pelvic area. R1 reported that they had a diaper on during the incident. On 01/23/2025, LPA Valeria Conway conducted an unannounced complaint visit to investigate the above allegations. When the LPA arrived, there were three (3) caregivers and six (6) residents present. Unsubstantiated The LPA was greeted by the caregiver, Robin Douglas. Caregiver contacted the Administrator, Loretta Tiede by phone. At 11:50 a.m. the Administrator arrived at the facility and was informed of the reason for the visit. At 11:55 AM., the LPA, along with Administrator Loretta Tiede, conducted a physical plant tour to ensure there are no immediate health and safety concerns. From 12:30 p.m. to 2:10 pm LPA conducted interviews with the administrator, three (3) caregivers, and a family member. Additionally, LPA attempted to interview two (2) residents and obtained copies of pertinent documents relevant to the investigation. On 07/16/2025, LPA Chochian conducted a subsequent visit and reviewed additional records including but limited to medication records and procedures. LPA interviewed staff and other potential witnesses on 07/16/2025 and telephonically on 07/18/2025. Staff interviews conducted revealed that R1 had a history of hallucinations and aggression towards staff and would make accusations against staff. Staff expressed being afraid to assist R1 in fear that R1 would make false accusations. Staff reported that R1 was not nice to staff and would make false accusations. During the telephonic interview with R1’s responsible person on 07/16/2025, they also expressed that R1 did have bouts of hallucinogenic episodes, memory issues and was agitated. Staff interviewed, Including S1 reported that they do not force medications on residents. Staff reported that if residents refused medication, they would give them time and try again later and if residents still refused, they would document and inform the family and physician. Staff and administrator reported that medications are given according to doctors’ orders. R1 did have a standing order for Seroquel 25mg. Facility medication records reviewed noted that R1 refused to take Seroquel on 01/17/2025 and on 01/19/20205 through 01/22/2025. During the 07/18/2025 telephonic interview, Staff #1 (S1) denied the allegation and reported that they last worked at the facility on or about 12/20/2024. S1 reported that they were not on duty on the alleged incident date and time. Although there is conflicting information on whether S1 worked on the night of the alleged incident. S1 expressed that when they worked at the facility, they treated the residents with respect and provided daily care with no issues and denied being inappropriate with any residents at the facility. A review of records, including but not limited to preplacement appraisal, medical assessment, and centrally stored medication record. R1 was admitted to the facility in August 2024. R1’s physician report dated 01/25/2025 noted history of short-term memory loss, mild confusion, agitation, and hallucinations. The previous medical assessment noted mild cognitive impairment, non-ambulatory, incontinent care services, and assistance with daily activities. During the 01/23/2025 visit, LPA Conway attempted to interview R1, although R1 declined to be interviewed about the alleged incident. Interview conducted with R1’s family member on 01/23/2025, did not reveal any initial reports of abuse by R1 to the family member. R1 has since passed away. During the subsequent visit on 07/16/2025, an attempt was made to interview other residents, however due to residents having cognitive issues the interviews were brief. One resident was able to communicate expressed that they are treated well and felt safe in the facility. A review of the Ventura County’s Sherriff’s (VCS) report revealed on 01/18/2025, a visit was conducted at the facility and R1, a Staff #2 (S2), and a friend of R1 were interviewed by the Officer. VCS was unable to determine that a crime occurred and closed their case after this visit. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations “Staff sexually abused resident in care and Staff forced resident to take medications” is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appealed rights were provided.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 29-AS-20250122081814

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 10:50 a.m. Upon arrival, there were two (2) staff and six (6) residents present. The LPA was greeted by facility staff who contacted the Administrator via telephone. At this time, the reason for the visit was explained. The facility manager, Robin Douglas arrived at 11:00 a.m. The Administrator, Loretta Tiede arrived during the inspection. Entrance interview conducted. The LPA along with the facility manager toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 11:20 a.m. Knives and sharps were observed in a locked drawer. Cleaning supplies were observed locked under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 127.9 degrees Fahrenheit at 11:24 a.m. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 11:37 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 10/15/2024. The LPA observed required postings throughout the common space. Emergency disaster drills conducted quarterly as per regulation; the last drill was conducted on 10/06/2024. Activities were observed in the common areas. There is a working telephone on premises. There is a laundry closet with a washer and dryer. Laundry detergent was observed in a locked cabinet above the washer and dryer. Report Continued on LIC 809C... Report Continued from LIC 809... RESTROOMS: There are three (3) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 109 degrees Fahrenheit at 11:10 a.m.; the second bathroom measured at 115.7 degrees Fahrenheit at 11:17 a.m.; and the third bathroom measured 134.2 degrees Fahrenheit at 11:31 a.m. Staff adjusted water temperature at the time of the inspection. BEDDROOMS: There are 6 (six) total bedrooms in the facility; one (1) is designated as a shared room, four (4) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. GARAGE/BACKYARD: The garage was locked and inaccessible to residents at the time of the visit. There is an additional refrigerator with perishable food, in good condition. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear of any obstructions. There is a side gate that is single latched. LPA observed a gated pool in the backyard that was locked and inaccessible at the time of the visit. RECORDS: LPA reviewed Resident Records at 12:04 p.m. and Personnel Records at 12:46 p.m. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were complete. Four (4) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Report Continued on LIC 809C... Report Continued from LIC 809C... MEDICATIONS: Medications review began at approximately 1:50 p.m. The medications are locked in a cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are labeled and checked for expiration dates. Medications appeared to be given as prescribed at the time of the visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 21, 2024

Type of visit: Case Management - Annual Continuation

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.the state’s words, verbatim · CDSS document, Nov 13, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:30 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Loretta Tiede arrived shortly thereafter. The LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 regulations. BEDROOMS/BATHROOMS: Beginning at 11:00 a.m. the LPA inspected the bedroom and bathroom areas. Bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are five designated resident rooms, one shared and four private resident rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. 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 measured between at 116.9 and 117.6 degrees Fahrenheit. KITCHEN: The LPA inspected the kitchen/food service area, knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. 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 of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested at 11:25 a.m. and operational at the time of the visit. The two fire extinguishers were fully charged and last serviced Oct 17, 2023. The LPA observed required postings throughout the common spaces. Continued on LIC 9099-C OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate that is single latched. There is a gated pool in the backyard that was locked and inaccessible a the time of the visit. Exits are free of obstructions. The garage is attached, locked and inaccessible with an additional refrigerator with perishable food. Cleaning supplies and disinfectants are kept in locked in the garage. There is a laundry closet located in the hallway where the washer and dryer are held laundry supplies are kept locked in a locked cabinet. The facility keeps a sufficient amount of emergency food supplies and water in the garage. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. RECORDS: Residents’ records review began at 12:15 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Due to time constraints, the LPA will return at a later date to complete the inspection. The LPA obtained the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Liability Insurance - Disaster Planthe state’s words, verbatim · CDSS document, Oct 30, 2023