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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808527
Report Date: 10/17/2023
Date Signed: 10/18/2023 10:25:39 AM

Document Has Been Signed on 10/18/2023 10:25 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 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: 74DATE:
10/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Kimberly Keane, Director of Program Development.TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Director of Program Development Kimberly Keane.

Today’s visit was in response to the death of Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1), which licensee self-reported. It was reported R1 passed away on October 12, 2023 at the facility.

According to records and interviews, C1 was admitted into the facility on September 1, 1992 with primary diagnoses of Down Syndrome, Mild ID, Dementia/Alzheimer's disease (On set on Alzheimer's Dementia February 25, 2011). C1 was placed under Sharp hospice care due to the progression of the Alzheimer's disease on July 19, 2023.

LPA briefly performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date.

An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were left with the Director, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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