<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603913
Report Date: 08/31/2022
Date Signed: 08/31/2022 12:30:31 PM


Document Has Been Signed on 08/31/2022 12:30 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: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:
08/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Debra Bunnell, Administrator and Nora Garcia, AdministratorTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 7/25/22. LPA Williamson identified herself and was granted entry into the facility by Caregiver Victoria Bozzo. LPA met with Administrators Debra Bunnell and Nora Garcia, and discussed the purpose of the visit.
R1
On 7/25/22, the facility submitted a self- reported incident. It was reported that a resident had an un-witnessed fall. Resident 1 (R1) (See LIC 811 Confidential Names List to identify ) was found on the floor in the hallway of the facility in front of their wheelchair covered in feces. R1 was assisted by Caregiver Victoria Bozzo and returned back to the wheelchair, assessed for injuries and cleaned up in the shower. While seated in the shower chair, R1 slid forward in the wheelchair and leaned to far and bumped their head on the shower wall. R1 denied hitting their head and being in pain. Caregiver heard R1's head hit the shower wall. Caregiver contacted 911, however when they arrived R1 refused to leave with the paramedics. R1 was assessed by the paramedics and there, were no injuries or concerns. R1 is ambulatory, however uses a wheelchair and requires the assistance of one caregiver for Activities of Daily Living (ADLs). R1's responsible party was notified.

During today’s visit, LPA briefly toured the facility, conducted staff interviews, reviewed resident 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: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1