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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410622
Report Date: 12/27/2022
Date Signed: 01/18/2023 10:14:30 AM

Document Has Been Signed on 01/18/2023 10:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NOAH'S ADULT HOMEFACILITY NUMBER:
336410622
ADMINISTRATOR:OLGA MORALESFACILITY TYPE:
735
ADDRESS:806 HOMESTEAD ROADTELEPHONE:
(951) 549-1314
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 5CENSUS: 3DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Yadira VazquezTIME COMPLETED:
10:30 AM
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On 12/27/2022 Licensing Program Analyst (LPA) Victoria Chitgian arrived to the facility at 9:40am to complete a required annual inspection. At the door, LPA was greeted by staff member Yadira Vazquez. Staff informed LPA that 2 (two) of their clients have tested positive for Covid-19 that morning. Staff proceeded to show the positive test results on a photo on their mobile device.
LPA asked staff to please report the cases to CCLD Duty Line. A business card was provided.
LPA will re-attempt the annual inspection at a future date.

1/18/2023 at 9:15am, Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA explained the purpose of the visit and met with Direct Support Person (DSP) Yadira Vazquez. There are currently no cases of COVID-19 within the facility.


During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed proper signs throughout the facility, sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring Personal Protective Equipment (PPE) supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control.

The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and clients for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NOAH'S ADULT HOME
FACILITY NUMBER: 336410622
VISIT DATE: 12/27/2022
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The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 illnesses.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of LIC 809 was provided to DSP Yadira Vazquez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023
LIC809 (FAS) - (06/04)
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