374604105-8-20-2021-08-AS-SJAB-C6EVDK-20210831162051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604105
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:59:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2020 and conducted by Evaluator Alexandre Vo

COMPLAINT CONTROL NUMBER: 08-AS-20200727113948

FACILITY NAME:	RENAISSANCE LIVING II		FACILITY NUMBER:	374604105
ADMINISTRATOR:	EDWARDS, RICHARD		FACILITY TYPE:	740
ADDRESS:	12536 JACKSON HILL LN		TELEPHONE:	(619) 334-0143
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92021
CAPACITY:	6	CENSUS: 5	DATE:	08/20/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Licensee, Richard Edwards		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Licensee did not provide resident records upon request

INVESTIGATION FINDINGS:

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Licensing Program Manager (LPM), Alexandre Vo, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPM met with Licensee, Richard Edwards, identified himself, and stated the purpose of the visit.

It was alleged that residents' documents were not provided upon request. Resident #1 (R1, see list of confidential names) relocated from the facility in May 2020 and sent a letter of request for documents, including Admission Agreement, financial papers, etc. A written letter of request was sent on July 8th, 2020, was received by the Administrator, Unique May, by certified mail on July 14th, 2020. Based on outside source records and interviews, Licensee did not comply within three business days for the record production response.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200727113948

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RENAISSANCE LIVING II	FACILITY NUMBER: 374604105
	VISIT DATE: 08/20/2021

NARRATIVE

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A deficiency is being issued in accordance with the Health and Safety Code and listed on the 9099D. The deficiency was also cleared because the licensee provided the required documents to the requesting entity.

An exit interview was conducted, and a copy of this report, Letter of Deficiency Cleared, and Licensee's Appeal Rights (9058 01/16) were provided to the Licensee, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 08-AS-20200727113948

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RENAISSANCE LIVING II	FACILITY NUMBER: 374604105
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/20/2021 Section Cited HSC 1569.269(a)(21)	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (21) To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days...	1 2 3 4 5 6 7	Licensee provided proof that the requested documents were delivered to the requestor. Deficiency cleared.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on records and interviews, the Licensee did not provide prompt access to resident records. This posed a potential personal rights risk to one of the five residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

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