374604232-1-23-2025-08-AS-CLOZ-DD7RRU-20250123121544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604232
Report Date: 01/23/2025
Date Signed: 01/23/2025 12:15:49 PM

Document Has Been Signed on 01/23/2025 12:15 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 II		FACILITY NUMBER:	374604232
ADMINISTRATOR/ DIRECTOR:	TERRI BOSTIAN		FACILITY TYPE:	740
ADDRESS:	16922 HIERBA DRIVE		TELEPHONE:	(858) 673-6333
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY: 140	TOTAL ENROLLED CHILDREN: 0	CENSUS: 54	DATE:	01/23/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Raquel Mathews, Director of Health and Wellness		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit for a report that was submitted to the San Diego Regional Office. LPA Lopez identified herself and was granted entry by the concierge Sabrina Uchino and Geizel Dasig. LPA stated the purpose of the visit and reviewed the basic elements of today’s visit with the Director of Health and Wellness Raquel Matthews (DHW). Today’s visit was in response to the death of Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1), which was reported to the San Diego Regional Office, Community Care Licensing Department (CCLD) on 01/10/2025. According to the IR, on 01/08/2025, the resident was getting ready to bathe when they lost their balance and fell. Facility staff were present, and a nurse was called to the scene. The nurse assessed the resident and determined the resident needed a higher level of care due to the resident’s condition and medication being taken. The nurse contacted emergency services and resident was taken to the hospital. The resident’s results returned with no evidence of mass, lesions, or acute cortical infarct or intracranial hemorrhage, and was returned to the community about 4 hours later. A caregiver was assisting the resident when the resident became unresponsive. Facility staff immediately contacted 911 and upon their arrival, the resident was pronounced deceased. On 01/23/25, LPA spoke with staff, and requested relevant facility records pertinent to this incident. According to facility records, the resident had underlying medical condition that required them to take anticoagulants since 2017. Records further indicated that the resident was a high fall risk but used an assistive device and was able to ambulate independently. Resident had a call device for assistance as needed. Records indicated that care staff would check on R1 every 2 hours. Additional records indicated that R1 had no evidence of acute intracranial hemorrhage or spinal fractures. According to further records, a waiver was provided by the medical examiner and a waiver number was provided to LPA. (Continuation on LIC809-C)

Robyn Clark	TELEPHONE: (619) 767-2312
Carmen Lopez	TELEPHONE: (619) 767-2301
	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: REMINGTON CLUB II	FACILITY NUMBER: 374604232
	VISIT DATE: 01/23/2025

NARRATIVE

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(Continuation of LIC809)

DHW said that they were notified via radio. Upon their arrival, they saw R1 was on the ground for no more than 5 minutes when 911 was initiated which included their arrival time to the room and in conducting a quick assessment of the R1 and determined they needed emergency response. They are aware that R1 was on anticoagulants which was a factor that contributed to contacting emergency response.

LPA informed the Health and Wellness Director that, at this time, the case requires additional telephone calls or visits relating to this incident. No deficiencies were identified or cited on this date.

An exit interview was conducted with Director of Health and Wellness, Raquel Matthews, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided at the conclusion of the visit. The signature below confirms the documents were received.

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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