374604052-7-31-2020-08-AS-SJAB-BS2TTL-20200731150054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604052
Report Date: 07/31/2020
Date Signed: 07/31/2020 01:24:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2019 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20191206095930

FACILITY NAME:	NOBLE LIVING III LLC		FACILITY NUMBER:	374604052
ADMINISTRATOR:	GARCIA, NORA		FACILITY TYPE:	740
ADDRESS:	6665 DECANTURE STREET		TELEPHONE:	(619) 542-9269
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	6	CENSUS: 4	DATE:	07/31/2020
		UNANNOUNCED	TIME BEGAN:	12:02 PM
MET WITH:	Administrator Nora Garcia, and Licensee Debbie Bunnell		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff are failing to make records available to the designated representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced video call to deliver findings on the above-mentioned allegation due to COVID-19. LPA identified herself and discussed the purpose of the call and the elements of the allegation with Administrator, Nora Garcia and Licensee, Debbie Bunnell.

The Department’s investigation consisted of staff interviews, records review and also a review of electronic correspondence between the facility and the reporting party.
In regard to the above-mentioned allegation, the RP alleged that staff (S1) withheld resident (R1) records from the authorized representative. Based on a review of the email correspondence, and the resident records, the facility staff sent the RP back all the paperwork included in R1’s facility file that are required by Title 22.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20191206095930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III LLC	FACILITY NUMBER: 374604052
	VISIT DATE: 07/31/2020

NARRATIVE

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Due to lack of corroborating evidence, the findings regarding the above allegation were established to be unsubstantiated. This finding means although the allegation may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted with Administrator, Nora Garcia and Licensee Debbie Bunnell via telephone and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) and documentation of Confidential Names (LIC 811) was provided to Administrator, Nora Garcia and Licensee Debbie Bunnell via email. An electronic email read receipt confirms the documents were received.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020

LIC9099 (FAS) - (06/04)

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