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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604232
Report Date: 01/12/2021
Date Signed: 01/13/2021 05:24:06 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:
(858) 673-6333
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:140CENSUS: 75DATE:
01/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Alison HumoraTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Natasha Persaud, contacted the facility via video conference due to COVID-19, to conduct a Case Management Visit. LPA identified herself and explained the purpose of the call to Administrator, Alison Humora.

The visit was in response to a self reported incident received on 01/08/21. Resident #1 (R1) eloped from the facility on 12/27/20. R1 was located within 15 minutes and redirected back to the facility, no injuries were sustained. The facility followed their elopement protocols, and R1 was provided additional supervision.

During the visual conference with the Administrator LPA requested information and records pertaining to R1's elopement. No deficiencies were issued during today's visit.

An exit interview was conducted with the administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), was 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].
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021
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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