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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808527
Report Date: 10/25/2022
Date Signed: 10/25/2022 03:49:27 PM

Document Has Been Signed on 10/25/2022 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: 77DATE:
10/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Gerardo Godinez, Senior Residential Support Manager and Carly McKim, Residential Support Manager TIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit. LPA identified herself and was granted entry by the Receptionist. LPA met with Gerardo Godinez, Senior Residential Support Manager and Carly McKim, Residential Support Manager and discussed the purpose of the visit.

On October 24, 2022, the facility self reported a resident death regarding Resident 1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing. This visit was conducted to follow-up with the death report.

During today’s visit, LPA briefly toured the facility, conducted interviews with Gerardo Godinez, Senior Residential Support Manager and Carly McKim, Residential Support Manager, requested and obtained relevant records. This case management visit requires further follow-up and a copy of the resident's death certificate was requested upon receipt. No deficiencies were cited during today’s visit.

An exit interview was conducted with Gerardo Godinez, Senior Residential Support Manager and Carly McKim, Residential Support Manager and a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC 9058 01/16) were provided to both Managers at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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