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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604442
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:35:42 PM


Document Has Been Signed on 07/07/2022 02:35 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:RENAISSANCE LIVING IIIFACILITY NUMBER:
374604442
ADMINISTRATOR:EDWARDS, RICHARDFACILITY TYPE:
740
ADDRESS:423 AVOCADO AVETELEPHONE:
(619) 954-0963
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:6CENSUS: 5DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Caregiver Maria Rios and Unique Maye, AdministratorTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced Required 1 -Year Visit. LPA identified herself and was greeted and allowed entry into the facility by Caregiver Maria Rios. LPA discussed the purpose of the visit via phone with Unique Maye, Administrator, who arrived to the facility shortly after the phone call.

LPA conducted a tour of the facility with Caregiver Maria Rios. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; A sign-in policy enacted for all visitors; Face coverings worn by staff; Hand sanitizer/hand washing stations readily available; A designated visitation area; Emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.

An exit interview was conducted with Unique Maye, Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 01/16) were provided to.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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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