331800204-10-17-2023-18-AS-JARA-CWPV9V-20231017161459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800204
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:15:05 PM

Document Has Been Signed on 10/17/2023 04:15 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	NOAH HOME		FACILITY NUMBER:	331800204
ADMINISTRATOR:	SAMANTHA PADILLA		FACILITY TYPE:	735
ADDRESS:	83279 PLAZA DE ORO		TELEPHONE:	(760) 601-7307
CITY:	COACHELLA	STATE: CA	ZIP CODE:	92236
CAPACITY: 4		CENSUS: 3	DATE:	10/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator, Stephanie Olivas		TIME COMPLETED:	04:30 PM

NARRATIVE

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On 10/17/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Stephanie Olivas, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (3) residents present.

The facility is a one story home with attached garage. No firearms or pools are present at the facility. The home has (4) bedrooms and (2) bathrooms. The clients served are adults ages 18 to 59 years of age. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed hand washing stations with hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train staff on infection control guidelines. The staff was unable to provide the infection control plan during the time of the visit. The administrator stated they would provide this to the LPA by 10/24/2023 to the LPA's email.

Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 111F.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NOAH HOME	FACILITY NUMBER: 331800204
	VISIT DATE: 10/17/2023

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Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. One (1) staff was found to not be associated to the facility. LPA verified the staff has a valid clearance. The facility will be cited for failure to associate the staff. Plan of correction was made with administrator. The listed administrator has a current administrator's certificate. Two (3) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in kitchen pantry. LPA reviewed resident medications, all of which were accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted 9/7/23. LPA observed emergency exits and emergency supplies.

An exit interview was conducted where a copy of this report, along with LIC809-D page, LIC421BG, and appeal rights were reviewed and provided to Administrator, Stephanie Olivas.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2023 04:15 PM - It Cannot Be Edited

Created By: Janira Arreola On 10/17/2023 at 04:02 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NOAH HOME	FACILITY NUMBER: 331800204
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with (1) staff S1 who was not associated to the facility, this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	The administrator agreed to send the LPA a transfer request to the LPA by the POC due date for S1.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Rikesha Stamps

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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