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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603465
Report Date: 06/20/2022
Date Signed: 06/20/2022 01:36:00 PM


Document Has Been Signed on 06/20/2022 01:36 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:RENOWN SUITESFACILITY NUMBER:
374603465
ADMINISTRATOR:MICHELLE RETZERFACILITY TYPE:
740
ADDRESS:8702 TOMMY DR.TELEPHONE:
(619) 466-9924
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY:6CENSUS: 6DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Blanca Vilchis, CaregiverTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Amy Domingo, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Blanca Vilchis, caregiver and we discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside. In accordance with the Department’s Infection Control, LPA evaluated and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

An exit interview was conducted. The Licensee was provided a copy of their appeal rights (LIC 9058 01/16), along with a copy of this report.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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