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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808527
Report Date: 06/07/2022
Date Signed: 06/07/2022 01:49:14 PM

Document Has Been Signed on 06/07/2022 01:49 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: 77DATE:
06/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH: Kimberly Keane, Director of Program Development and Gerardo Godinez, Senior Residential Support ManagerTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit. LPA Williamson identified herself and was granted entry into the facility by the receptionist. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Kimberly Keane, Director of Program Development and Gerardo Godinez, Senior Residential Support Manager.

On May 25, 2022, the facility self reported the death of Client 1(C1) (See LIC 811 Confidential Names List) to Community Care Licensing. The facility reported that on May 24, 2022, Caregiver Karrina Koskinen observed that C1's breathing pattern had changed to a shallow and faint breathing. Hospice staff, Senior Residential Support Manager were contacted and reported to the facility. Robert Richardson, LVN confirmed that there was no pulse nor vital signs present in C1. C1 was pronounced deceased on May 24, 2022 at 10:50 PM at the facility. C1 was admitted to hospice care on April 22, 2022.

During today's visit, LPA conducted staff interview, and requested and obtained records. No deficiencies were cited during the visit.

An exit interview was conducted with Gerardo Godinez, Senior Residential Support Manager and a copy of this report, LIC 811 and Licensee Appeal Rights (LIC9058 01/16) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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