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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881043
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:17:50 PM

Document Has Been Signed on 10/20/2022 02:17 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
, 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:
10/20/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ruth Anguiano- AdministratorTIME COMPLETED:
02:27 PM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility. LPA Gardner met with Administrator Ruth Anguiano and explained the reason for the visit.

The Health and Safety check included overall observation of the facility inside, and outside, including food supply, medications, and physical plant. LPA Gardner did not observe any safety hazards.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Administrator Ruth Anguiano.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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