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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603913
Report Date: 07/08/2022
Date Signed: 07/08/2022 11:27:53 AM


Document Has Been Signed on 07/08/2022 11:27 AM - 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: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: 4DATE:
07/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Debra Bunnell, Administrator and Nora Garcia, AdministratorTIME COMPLETED:
11:30 AM
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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 Caregiver Amy Duell. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Debra Bunnell, Administrator and Nora Garcia, Administrator

On July 7, 2022, the facility reported a resident death regarding Resident 1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing. The facility reported that on June 29, 2022, R1 passed away at the facility at approximately 2:45 p.m.

During today’s visit, LPA briefly toured the facility, conducted staff interviews, requested and obtained resident and facility records. No deficiencies were cited during today’s visit.

An exit interview was conducted with Debra Bunnell, Administrator and Nora Garcia, Administrator a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC 9058 01/16) was provided to Administrators.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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