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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604232
Report Date: 09/08/2021
Date Signed: 09/09/2021 03:09:33 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: 78DATE:
09/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Alison HumoraTIME COMPLETED:
12:43 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management- Incident visit. LPA met with Administrator, Alison Humora and discussed the purpose of the visit.

During today's visit, LPA briefly toured the facility, requested records and interviewed staff and residents. On 08/30/21, Community Care Licensing received a self reported incident involving Resident #1 (R1) and Staff #1 (S1). The alleged incident occurred on 08/23/21 at the facility. The incident report stated S1 was ringing out a towel and hit R1 with the towel, no injury was sustained. No deficiencies were issued.

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

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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