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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808527
Report Date: 09/15/2023
Date Signed: 09/15/2023 01:10:34 PM

Document Has Been Signed on 09/15/2023 01:10 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
SAN DIEGO RO, 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:
09/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Residential Support Manager Salvador AntonTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Case Management - Incident visit. LPA was allowed entry by reception staff. Residential Support Manager Salvador Anton met with LPA, with whom LPA introduced herself and discussed the purpose of the visit.

Today's visit was in response to a client's death (C1) on 08/21/2023. The facility attempted to submit the Death Report with Special Incident Report to CCLD on the same day but transmission failed. During today's visit, LPA was presented with copies of the Death Report and Special Incident Report. (See LIC811 Confidential Names List for a description of C1.)

During today's visit, LPA performed a brief tour of the facility and welfare check on clients present, finding no safety concerns.

According to records and interviews, C1 was admitted into the facility in July 2017 with primary diagnoses of Down Syndrome, Mild ID, Dementia/Alzheimer's disease. C1 was placed under hospice care due to Alzheimer's disease in May 2019 and graduated in March 2023. On 06/24/2023, C1 was re-admitted into hospice care also due to Alzheimer's disease and was on hospice at the time of death.

No deficiencies were cited for C1's death. No other deficiencies were observed or cited during today's visit. Mr. Anton stated that a copy of the death certificate will be obtained by the facility and submitted to CCLD as soon as available.

An exit interview was conducted with Mr. Anton, to whom a copy of this report, LIC811 (Confidential Names List), and the Applicant/Licensee Rights (LIC9058 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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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