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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604232
Report Date: 01/11/2021
Date Signed: 01/11/2021 02:53:08 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: 74DATE:
01/11/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Administrator Alison HumoraTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Raymond Wu conducted an unannounced virtual visit, due to COVID-19, to conduct a Case Management Visit. LPA identified himself and explained the purpose of the call to Administrator, Alison Humora.

The visit was in response to a Death Report submitted by the Licensee on 01/06/2021 regarding Resident #1 (R1; See LIC 811 Confidential Names List).

During today's visit, LPA requested information and records pertaining to R1's death. No deficiencies were observed or issued during today's visit.

An exit interview was conducted with Humora and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), was provided to the Licensee via electronic mail. An electronic read receipt confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Raymond WuTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2021
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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