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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603913
Report Date: 01/20/2023
Date Signed: 01/20/2023 01:25:40 PM


Document Has Been Signed on 01/20/2023 01:25 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:
01/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Debra Bunnell, LicenseeTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced case management visit to cite deficiency noted during a complaint investigation. LPA was granted entry by Victoria Bozzo, caregiver, after identifying herself. LPA discussed the purpose of the visit with Nora Garcia, Administrator. The Department’s investigation consisted of review of facility records, and interviews with facility staff, residents, and outside sources. Licensee Debra Bunnell arrived during the visit.

On November 17, 2022, Resident 1 (R1) passed away. Facility records indicated R1’s personal belongings were removed on November 20, 2022. Facility records also showed a refund check was issued on December 9, 2022. From the day the personal belongings were removed to the day the refund check was issued was nineteen (19) days.

On June 29, 2022, facility records indicated Resident 2 (R2) passed away and personal belongings were removed the same day. Facility records also showed a refund check was issued on July 20, 2022. From the day the personal belongings were removed to the day the refund check was issued was twenty-one (21) days.

Licensee stated that refund checks were requested online through the bank. The bank, subsequently, does not send out the refund checks immediately, but takes an unknown amount of days to process.

Based on the evidence obtained during the investigation, pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC809D and a plan of correction was jointly developed with Licensee. An exit interview was conducted; a copy of this report and Licensee's Rights (LIC9058) were provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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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Document Has Been Signed on 01/20/2023 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 374603913

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2023
Section Cited

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Refund of fees paid: (c) A refund of any fees paid in advance ... covering the time after the resident’s personal property has been removed... shall be issued ... within 15 days after the personal property is removed. This requirement is not met as evidenced by:
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Licensee will issue manual checks for all future refunds. A signed in service training log for section HSC 1569.652 will be provided to LPA as proof of training.
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Based on interviews and record reviews, the licensee did issue a refund after a resident’s death in 2 of 7 residents, which posed a personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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