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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604232
Report Date: 01/29/2024
Date Signed: 01/29/2024 03:34:22 PM

Document Has Been Signed on 01/29/2024 03:34 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:REMINGTON CLUB IIFACILITY NUMBER:
374604232
ADMINISTRATOR:TERRI BOSTIANFACILITY TYPE:
740
ADDRESS:16922 HIERBA DRIVETELEPHONE:
(858) 673-6333
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 140CENSUS: 62DATE:
01/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Director of Resident Care Raquel Mathews and Executive Director Kevin BoothTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an unannounced visit to continue a Required Annual Inspection which began on 01/22/2024. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Director of Resident Care Raquel Mathews and Executive Director Kevin Booth.

According to the facility’s license, the facility has a maximum capacity of 140 residents, of which 82 may be non-ambulatory and 16 may be bedridden. During today’s inspection, there were a total of 62 residents in care, of which 59 were non-ambulatory, 3 were ambulatory, and zero were bedridden. The facility's fire clearance did not include endorsements for delayed-egress doors or secured perimeter, and neither were present during today's visit. The submitted facility sketch was consistent with the current layout of the facility.

During the annual inspection, LPAs, accompanied by licensee’s staff, toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. LPAs privately interviewed multiple staff and residents. LPAs also reviewed multiple staff and resident records/files.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained required furniture. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment (PPE). The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Confidential records and centrally stored medications were kept in locked areas.


[CONTINUED ON LIC 809-C, 1 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 01/29/2024 03:34 PM - It Cannot Be Edited


Created By: Dang Nguyen On 01/29/2024 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: REMINGTON CLUB II
FACILITY NUMBER: 374604232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and manager interview, Licensee did not maintain a report of a health screening for 2 of 5 staff sampled (S1 and S2). This posed a potential health and safety risk to residents in care.
POC Due Date: 02/28/2024
Plan of Correction
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Licensee agreed to arrange for S1 and S2 to each be seen by a doctor, for the purposes of completing a health screening report. Licensee agreed to E-mail LPA the LIC503 Health Screening (or an equivalent form) for both S1 and S2, with negative TB test result, by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2024 03:34 PM - It Cannot Be Edited


Created By: Dang Nguyen On 01/29/2024 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: REMINGTON CLUB II
FACILITY NUMBER: 374604232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation: “(e)(2) Faucets used by residents for personal care… shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F…and not more than 120 degree F…”

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA measurement, for 5 of 5 sampled bedrooms, Licensee did not ensure controls were maintained to automatically regulate the temperature of hot water used by residents to be between 105 F and 120 F. This posed a potential safety risk to residents in care.
POC Due Date: 01/29/2024
Plan of Correction
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During the LPA’s site inspection, Licensee adjusted the facility’s boilers to lower the water temperature. When the same sink taps were retested, all were within the required 105 F to 120 F range. This action resolves the deficiency.
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements – General: “(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training… (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.”

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and manager interview, Licensee did not ensure that 2 of 2 staff sampled (S3 and S4), who routinely assist residents with activities of daily living, received appropriate training in first aid from a qualified agency. This posed a potential health and safety risk to residents in care.
POC Due Date: 02/28/2024
Plan of Correction
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Licensee agreed to arrange for S3 and S4 to complete first aid training from a qualified agency, and to E-mail their respective first aid training certification cards to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


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Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: REMINGTON CLUB II
FACILITY NUMBER: 374604232
VISIT DATE: 01/29/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

The facility had at least two days of perishable food and seven days of non-perishable food present. The facility had cooking and dining utensils to facilitate resident meal service. The Main Kitchen Walk-In Refrigerator’s temperature was compliant at 40 F, and the Main Kitchen Walk-In Freezer’s temperature was complaint at 0 F. The auxiliary Walk-In Refrigerator was compliant at 40 F. The facility’s ambient internal temperature was compliant at 76 F.

There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents for whom they would be a danger. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility.

Smoke and fire alarms, carbon monoxide detectors, emergency lighting, signals system, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. A complete first aid kit was present and readily accessible. Licensee's staff also presented proof of current/active business liability insurance. Required licensing postings were observed in visible areas of the facility.

Where tested, hot water temperature at taps (which were used by residents for personal care) were initially non-compliant: Bedroom #103 sink was 128 F, Bedroom #112 sink was 125 F, Bedroom #142 sink was 128 F, Bedroom #210 sink was 122 F, and Bedroom #241 sink was 129 F. During the course of the annual inspection, Licensee adjusted the facility’s boilers to bring the water temperatures down to the compliant range.

During a review of a sample of employee files, LPAs observed, and manager interview confirmed: Licensee did not maintain written evidence of a completed physical / health screening for Staff #1 (S1) and Staff #2 (S2) from time of hire, as was required. [See LIC811 Confidential Names List of select person identifiers used in this report.] Licensee did not maintain proof of current First Aid training for Staff #3 (S3) and Staff #4 (S4), both of whom assist residents with personal Activities of Daily Living (ADLs), as was required.


[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: REMINGTON CLUB II
FACILITY NUMBER: 374604232
VISIT DATE: 01/29/2024
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction was jointly developed with Licensee. LPAs also issued Technical Assistance (TA) regarding infection control and training records (see the LIC 9172-TA pages).

An exit interview was conducted with Mathews and Booth, to whom a copy of this report, the LIC 809-D pages, the LIC9172-TA pages, 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: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
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