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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604232
Report Date: 06/18/2024
Date Signed: 06/18/2024 02:19:52 PM


Document Has Been Signed on 06/18/2024 02:19 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
SAN DIEGO RO, 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: 61DATE:
06/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Executive Director Amy Divas and Resident Service Director Raquel MathewsTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management visit. LPA Lopez identified herself and was granted entry by concierge Sabrina Uchino. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Resident Service Director Raquel Mathews. Executive Director Amy Divas later arrived and joined the visit.

This visit was in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on Friday, June 14, 2024. The IR said that there was an incident that had transpired on Saturday, June 8, 2024, with resident #1 (R1) who sustained injuries.

During today's visit LPA Lopez spoke with staff and resident and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified that R1 was visiting with another resident #2 (R2) when the incident transpired. According to the IR and R2 confirmed, R1 had slid off a bed, and staff was called to assist R1. R1 did not report any pain and ambulated to activities per usual. R1s responsible party was notified of the incident. Per Resident Service Director, at that time paramedics were not contacted as R1 had full range of motion and did not report any pain. R1's RP visited the morning of June 10, 2024, when R1 reported feeling pain. Paramedics were immediately contacted and R1 was taken to the hospital. R1 is currently at a rehabilitation center and plan of care will be updated upon to R1s return to the facility. LPA informed Resident Service Director Mathews that there may be further follow-up telephone calls or visits necessary for this incident. No deficiencies were cited during today’s visit.

An exit interview was conducted with Resident Service Director Raquel Mathews, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided to Resident Service Director Raquel Mathews at the conclusion of the visit. The signature below confirms that the documents were received.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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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