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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603465
Report Date: 06/17/2024
Date Signed: 06/18/2024 07:50:59 AM


Document Has Been Signed on 06/18/2024 07:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Caregiver Blanca VilchisTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Blanca Vilchis. Administrator Michelle Retzer arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six residents, of whom all may be non-ambulatory.

LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required and kept inaccessible to residents.


No bodies of water were present. Per Michelle, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible.

Resident records reviewed were missing 5 resident needs and services. Per Michelle, documents are being updated at this time. Staff records reviewed contained required documentation.

One technical advisory was issued for missing needs and services plans. No additional deficiencies were cited on today's visit.

An exit interview was conducted with Administrator Michelle Retzer, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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