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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800204
Report Date: 10/22/2024
Date Signed: 10/22/2024 12:25:00 PM

Document Has Been Signed on 10/22/2024 12:25 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 HOMEFACILITY NUMBER:
331800204
ADMINISTRATOR/
DIRECTOR:		SAMANTHA PADILLAFACILITY TYPE:
735
ADDRESS:83279 PLAZA DE OROTELEPHONE:
(760) 601-7307
CITY:COACHELLASTATE: CAZIP CODE:
92236
CAPACITY: 4CENSUS: 4DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Stephanie OlivasTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted by the administrator Stephanie Olivas, notified her of the purpose for the visit and was allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a single story building with 4 residents bedrooms, 2 bathrooms and a garage There is no gated pool and there are no firearms on the premises.

Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in kitchen cabinet next to the fridge and inaccessible to residents. The smoke detector and carbon monoxide detector were operational. L observed fire extinguishers to be in compliance with the department requirements and with and expiration date of 09/14/2025. LPAs observed the hot water temperature to meet requirements at 112.2°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.


Continued on LIC809-C.....
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NOAH HOME
FACILITY NUMBER: 331800204
VISIT DATE: 10/22/2024
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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of May 27th, 2026 and a CPR certification with the expiration date of 08-18-26

Record Review and Resident/Staff Files: LPAs reviewed files for three(3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Four residents' files were reviewed and contained all required documentation. LPA's observed Staff, resident files, were stored in a cabinet in the garage as well as the emergency food. The first aid kit was stored in a cabinet in the kitchen area.


Health-Related Services/Incidental Medical Services: All residents' medications were securely locked and located in the kitchen area. LPA reviewed medications for four residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 10-03-2024, which met department requirements. All facility exits were clear of obstructions.



No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Stephanie Olivas
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
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