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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603913
Report Date: 09/13/2021
Date Signed: 09/14/2021 07:54:54 AM

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:BUNNELL, DEBRAFACILITY TYPE:
740
ADDRESS:505 HILLS LANE DRTELEPHONE:
(619) 938-4984
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:6CENSUS: 6DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Licensee, Debra BunnellTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA), Alexandre Vo, conducted an unannounced annual required licensing inspection. LPA was granted entry by Licensee, Debra Bunnell, after identifying himself and disclosing the purpose of the visit. LPA also met with Administrator, Nora Garcia. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with infection control practices.

The tour was conducted with the Administrator and the Licensee. LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Infection Control, including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility's Plans for Infection Control and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

LPA reviewed items pertaining to central entry points for universal entry screening; routine symptom screening initiated for staff, residents and visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE.

No deficiencies were cited during this visit. Technical assistance was provided regarding N-95 fit-testing per PIN 21-10-ASC.

An exit interview was conducted with the Licensed. A copy of this report, along with the Licensee Rights (9058 01/16) were provided to the Licensee and Administrator via e-mail. A confirmation e-mail was requested.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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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