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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808527
Report Date: 03/08/2022
Date Signed: 03/09/2022 09:11:05 AM

Document Has Been Signed on 03/09/2022 09:11 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
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:
03/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:COO, Sandra Rocco-MelvilleTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted a Case Management - Other visit. LPA met with COO, Sandra Rocco-Melville. LPA stated the purpose of the visit was to follow up on a death of a client.

During today's visit, LPA briefly toured the facility, requested records, and interviewed staff. On 03/07/22, Community Care Licensing received a death report for Client #1 (C1). The report stated on 03/04/22, C1 underwent a medical procedure at the hospital. C1 passed away after the medical procedure at the hospital on 03/04/22. No deficiencies were issued today.

An exit interview was conducted with COO, Sandra Rocco-Melville and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the COO, Sandra Rocco-Melville via electronic mail. An electronic read receipt confirmation was requested to be sent by the COO upon receipt of the documents. [See LIC 811 Confidential Names List to identify Client #1]
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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