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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808527
Report Date: 11/18/2021
Date Signed: 11/18/2021 03:49:43 PM

Document Has Been Signed on 11/18/2021 03:49 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: DATE:
11/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:09 PM
MET WITH:Gerardo GodinezTIME COMPLETED:
04:25 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) Kennedy conducted a case management visit to complete a review regarding a self-reported death of Client 1 (C1) (See LIC 811 for confidential names) received by CCL on 11-17-21. LPA met with Gerardo Godinez, Senior House Manager and discussed the purpose of the visit.

LPA reviewed C1's facility file and hospice care notebook, and interviewed staff about events leading up to death. C1 resided at the facility since 2017 and was admitted to hospice on 8-30-21. The hospice agency provided comfort measures, facility staff training and health monitoring to C1 through the end of C1's life. The death of C1's was expected.

No deficiencies were cited during the visit.

An exit interview was conducted with Gerardo Godinez. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to the facility via email. An electronic response confirms the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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