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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808527
Report Date: 12/02/2022
Date Signed: 12/02/2022 01:22:14 PM

Document Has Been Signed on 12/02/2022 01:22 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:NOAH HOMES, INC.FACILITY NUMBER:
370808527
ADMINISTRATOR:MOLLY NOCONFACILITY TYPE:
735
ADDRESS:12526 CAMPO ROADTELEPHONE:
(619) 660-6200
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91978
CAPACITY: 78CENSUS: 75DATE:
12/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Carly McKim, House ManagerTIME COMPLETED:
01:25 PM
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Licensing Program Analysts (LPAs), Tammer De Los Santos and Kayla Hilario, conducted an unannounced Case Management visit. LPAs were allowed entry by receptionist and discussed the purpose of the visit with Director Kim Keane. LPAs met with Residential Support Manager Carly McKim. All staff present had current criminal record clearance.

Today's visit was in response to self-reported death of Client #1 (C1). [See LIC 811 Confidential Names List for a description of C1]. C1 was on hospice and passed on 11/27/2022 at the facility. LPAs conducted interviews with staff, collected records, and conducted a tour of the facility.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Residential Support Manager Carly McKim to whom a copy of this report and an appeal rights (LIC9058 03/22) were provided via hardcopy of the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tammer DeLosSantos
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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