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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808527
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:14:08 PM

Document Has Been Signed on 09/29/2022 04:14 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: 78DATE:
09/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Kimberly Keane, Director of Program DevelopmentTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on incident report received by Community Care Licensing on 9/23/22. LPA met with Kimberly Keane, Director of Program Development and discussed the purpose of the visit.

On 9/23/22, LPA received a self- reported incident report from the facility regarding Staff (S1) slapping a client on the cheek sustaining no injuries. On 9/21/22, Client 1 (C1) reported to Staff 2 (S2) that Staff 1 (S1) slapped them on the cheek. C1 confirmed there was no pain, and staff did not observe bruising or redness.

During today's visit, LPA Williamson conducted interviews with facility staff, C1 and reviewed client records. This incident will require additional investigation.

No deficiencies were issued during today's visit. An exit interview was conducted with Kimberly Keane, Director of Program Development, to whom a copy of this report, Confidential Names (LIC 811) and the Licensee's/Appeal Rights (LIC 9058 01/16) were provided to Director of Program Development.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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