<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808527
Report Date: 07/07/2023
Date Signed: 07/07/2023 01:53:02 PM

Document Has Been Signed on 07/07/2023 01:53 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, 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: 76DATE:
07/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Memory Care Senior Residential Support Manager Gerardo Godinez and Resident Support Manager Salvador AntonTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Memory Care Senior Residential Support Manager Gerardo Godinez and Resident Support Manager Salvador Anton.

Today's visit was in response to two (2) LIC624A Death Reports, which licensee self-submitted to the CCLD San Diego Regional Office (RO). The first LIC624A (received on 06/23/2023) described Client #1 (C1) passing away on 06/23/2023. The second LIC624A (received on 07/06/2023) described Client #2 (C2) passing away on 07/05/2023. [See LIC 811 Confidential Names List for a description of the person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour / welfare check on remaining clients, finding no safety concerns. LPA also collected copies of pertinent records and interviewed relevant staff.

According to records and interviews: C1 was diagnosed with Alzheimer's Disease starting in 2010, and C2 was diagnosed with Alzheimer's Disease starting in 2016. Both C1 and C2 were under the care of hospice agencies when they each passed away.

No deficiencies were cited for the deaths of C1 or C2. Also, no deficiencies were observed or cited during today's visit.

An exit interview was conducted with Anton, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1