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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881043
Report Date: 09/16/2021
Date Signed: 09/16/2021 04:27:56 PM

Document Has Been Signed on 09/16/2021 04:27 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NOAH'S ARK ADULT HOMEFACILITY NUMBER:
331881043
ADMINISTRATOR:ANGUIANO, RUTHFACILITY TYPE:
735
ADDRESS:20094 KLYNE ST.TELEPHONE:
(951) 707-6803
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 4CENSUS: 2DATE:
09/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Ruth AngianoTIME COMPLETED:
04:28 PM
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced case management visit to discuss an incident report received on 8/23/2021. LPA met with administrator Ruth Angiano.

Ms. Angiano stated Client 1 (C1) moved out of the facility on 7/10/2021 but prior C1 moving out, C1 had never reported this type of allegation to any staff. She stated no other clients living in the home ever reported this type of allegation. She stated C1 would have verbalized this type of allegation to staff. She stated Client 2 (C2) never displayed any behaviors described in the incident report. Records indicate C2 moved to another facility on 2/26/2021. LPA obtained copies of pertinent documents.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.


SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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