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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 01:54:05 PM

Document Has Been Signed on 06/07/2022 01:54 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 - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Kimberly Keane, Director of Program Development and Tammy Levitt, Senior Residential Support Manager TIME COMPLETED:
02:00 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 met with Kimberly Keane, Director of Program Development and Tammy Levitt, Residential Support Manager.

On May 24, 2022, the facility self reported an incident involving Client 1(C1) (See LIC 811 Confidential Names List) to Community Care Licensing. The facility reported that on May 24, 2022, C1 was observed falling to the floor, landing in a sitting position. After the fall, C1 did not complain of any pain and there were no injuries observed by staff. LPA conducted an interview with Tammi Levitt, Residential Support Manager and it was determined that C1 actually fell on May 21, 2022. On May 23, C1 complained of pain in the feet and was observed to be hesitant when walking. C1's primary physician was contacted by Residential Support Manager and a video visit was conducted for C1. It was determined during the video doctor's visit that C1 be taken to the hospital. C1 was unable to communicate the actually area where the pain was located. On May 24, 2022, C1 was transported to the hospital, treated and released.

During today's visit, LPA reviewed C1's records and conducted an interview with staff and C1. LPA and Tammi Levitt, Residential Support Manager discussed Community Care Licensing Reporting Requirements. No deficiencies were cited during the visit.

An exit interview was conducted with Tammi Levitt, 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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