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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604232
Report Date: 11/30/2021
Date Signed: 12/01/2021 12:54:15 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: 76DATE:
11/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Administrator, Alison HumoraTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management- Other visit. LPA met with Administrator, Alison Humora and discussed the purpose of the visit.

During today's visit, LPA briefly toured the facility, obtained records, and interviewed staff. On 11/24/21, Community Care Licensing received a Death Report involving Resident #1 (R1). R1 passed away at the facility on 11/18/21. No deficiencies were issued today.

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: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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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