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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604232
Report Date: 09/15/2020
Date Signed: 09/16/2020 12:23:02 PM

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:REMINGTON CLUB IIFACILITY NUMBER:
374604232
ADMINISTRATOR:HUMORA, ALISONFACILITY TYPE:
740
ADDRESS:16922 HIERBA DRIVETELEPHONE:
(617) 796-8350
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:140CENSUS: 83DATE:
09/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Administrator, Alison HumoraTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA), Natasha Persaud, contacted the facility via telephone to conduct a Case Management Visit regarding an incident. The visit is being conducted via telephone due to COVID-19. LPA identified herself and explained the purpose of the call to Administrator, Alison Humora

During the visual conference with the Administrator, LPA briefly toured the facility, interviewed staff and Resident #1 (R1) and requested resident records

On 09/09/20, Community Care Licensing received an incident report involving R1 and Staff #1 (S1). The administrator provided additional follow up involving the incident. No deficiencies were issued.

An exit interview was conducted with Alison Humora, Administrator, via virtual visit, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents. [See LIC 811 Confidential Names List to identify Resident #1 and Staff #1]
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020
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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