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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604150
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:36:44 PM

Document Has Been Signed on 02/21/2024 03:36 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:NOELLE RESIDENTIAL AT RINGWOODFACILITY NUMBER:
374604150
ADMINISTRATOR:MELENA, MIAFACILITY TYPE:
735
ADDRESS:440 RINGWOOD DRTELEPHONE:
(619) 439-6318
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 4CENSUS: 3DATE:
02/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:House Manager Kaleb Haupu and Administrator Mia MelenaTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with House Manager Kaleb Haupu. LPA also met with Administrator Mia Melena, who arrived later during the visit.

Today's visit was in response to a Special Incident Report (SIR), which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/06/2024), involving Client #1 (C1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a facility tour and welfare check, verifying that C1 and their house mates were safe. LPA collected copes of pertinent care records and interviewed relevant staff.

No deficiencies were cited during today’s visit.

An exit interview was conducted with Melena, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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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