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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603913
Report Date: 07/02/2020
Date Signed: 07/29/2020 04:55:12 PM

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:NOBLE LIVING II LLCFACILITY NUMBER:
374603913
ADMINISTRATOR:LEON, REBECCAFACILITY TYPE:
740
ADDRESS:505 HILLS LANE DRTELEPHONE:
(619) 938-4984
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:6CENSUS: 5DATE:
07/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Rebecca Leon, AdministratorTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Lizzette Tellez conducted a case-management televisit due to COVID-19. LPA identified herself to the Administrator, Rebecca Leon, and we discussed the purpose of the visit.

LPA is conducting a death investigation regarding Resident #1 (R1). Ms. Leon was provided with Confidential Names Form in order to identify R1. A Death Report for R1 was received in the San Diego Regional Office on June 30, 2020.

During today's televisit, LPA toured the facility, interviewed staff, and requested copies of R1's records and death certificate. No immediate health and/or safety concerns were observed during the televisit.

No deficiencies were cited during today's televisit. An exit interview was conducted with Ms. Leon. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to her via email.

This is an amended version of a report signed on July 2, 2020.
SUPERVISOR'S NAME: Tony GirolamiTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2020
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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