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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603906
Report Date: 12/09/2025
Date Signed: 12/11/2025 08:14:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
08/13/2023 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20230813115402
FACILITY NAME:RENAISSANCE LIVINGFACILITY NUMBER:
374603906
ADMINISTRATOR:RICHARD EDWARDSFACILITY TYPE:
740
ADDRESS:9112 WAKARUSA STREETTELEPHONE:
(619) 741-2499
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 5DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gabriela Nafarrate CaregiverTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff are not adequately trained
Staff did not follow reporting requirements
Staff did not treat resident with dignity
Staff did not treat resident with respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Gabriela Nafarrate Caregiver and Unique Edwards Administrator was notified via a telephone call.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources.

On April 20, 2023, it was alleged that the staff are not adequately trained. Outside Source 1 (OS1) observed the staff not being able to recognize R1's behaviors as possibly unmet needs (e.g., pain, fear, confusion). OS1 observed the staff not following the most basic person center approaches as in speak calmly and use


This is an amended report from 9/12/25.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 08-AS-20230813115402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: RENAISSANCE LIVING
FACILITY NUMBER: 374603906
VISIT DATE: 12/09/2025
NARRATIVE
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simple, clear language, avoid arguing; redirect gently. Maintain familiar routines and offer choices.  The staff were not displaying good  communication techniques, behavior management, and emergency response.  They were not objective. The staff did not records triggers, interventions and outcomes.  The staff did not utilize the basic standardized behavior tracking tools to assist R1 with adjusting to a new environment.

On April 20, 2023, an allegation was received stating that facility staff did not follow required reporting procedures. Interviews conducted with staff indicated that they were familiar with reporting protocols and stated that incident reports were completed when residents exhibit unusual behaviors. However, documentation did not support these claims.

A review of facility records revealed no incident reports, internal documentation, or other evidence indicating reports were completed for R1 during periods of unusual behavior. Additionally, Outside Source 4 (OS4) confirmed they were not notified of any incidents involving R1. This lack of documentation and communication was inconsistent with the facility’s obligation which requires licensees to report unusual incidents and maintain accurate records. The absence of incident reports and not notifying OS4 suggest noncompliance with reporting requirements.

On April 20, 2023, an allegation was made that the facility staff did not treat the residents with dignity. Interviews were conducted with two (2) residents. The residents that were interviewed stated that staff treat them with dignity and respond to their needs in a timely and courteous manner.

Outside source 3 (OS3) reported concerns regarding staff conduct and described staff as not compassionate nor professional. Outside Source 3 (OS3) stated that the facility staff were very unprofessional. The facility staff texted or called OS4 with multiple complaints that R1 was unruly and difficult to work with. Outside source 5 (OS5) reported witnessing undignified treatment towards R1 when transferring R1 to an alternative placement. OS5 was interviewed and they verified that the facility staff did not treat R1 with respect. The staff did not show dignity in packing R1's belongings when being transferred to another facility and cheering when the resident left the facility.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230813115402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: RENAISSANCE LIVING
FACILITY NUMBER: 374603906
VISIT DATE: 12/09/2025
NARRATIVE
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A review of staff training records confirmed that all staff received training on resident rights regarding being treated with dignity. During the visit, staff were observed interacting with residents in a dignified and professional manner. Staff addressed residents by name, and offered assistance in a courteous way. The residents that the staff were assisting did not have dementia related behaviors.

On April 20, 2023, an allegation was made that the facility staff did not treat the residents with respect. Interviews were conducted with two (2) residents. The residents that were interviewed stated that staff treat them with respect and respond to their needs in a timely and courteous manner. Interviews with two (2) staff members revealed that staff were aware of and trained on resident rights, including the importance of treating residents with respect. Staff were able to articulate examples of how they uphold these standards in their daily interactions.

OS3 reported concerns regarding staff conduct and described staff as disrespectful. OS4 stated that the staff at the facility did not treat R1 with respect. OS5 was interviewed and they verified that the facility staff did not treat R1 with respect. They did not show respect in packing R1's belongings when being transferred to another facility and cheering when the resident left the facility

A review of staff training records confirmed that all staff received training on resident rights.  During the visit, staff were observed interacting with residents in a respectful and professional manner. Staff addressed residents by name, offered assistance in a courteous way. The residents that the staff were assisting did not have dementia related behaviors.

The department has investigated the above-mentioned allegations. The Department has found that there is a preponderance of evidence to prove that the alleged violation did occur; therefore, the allegations are substantiated.

An exit interview was conducted, and a copy of this report and the licensee rights (LIC 9058 03/22) were provided to Gabriela Nafarrate Caregiver. Her signature on this form confirms receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20230813115402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RENAISSANCE LIVING
FACILITY NUMBER: 374603906
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2026
Section Cited
HSC
1569.624(c)(8)
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Staff training: Mandates that staff working in Residential Care Facilities for the Elderly (RCFEs) receive training appropriate to the services they provide, including dementia care if applicable.
This requirement was not met as evidence by;

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Administrator agrees to conduct a staff dementia training for all staff and administrators by 1/12/2026.
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Based on interviews the staff did not show staff training of one of six persons in care which posed a potential Health and Safety risk to person in care.
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Type B
01/10/2026
Section Cited
CCR
87211(a)(1)
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Reporting Requirements: licensees to report unusual incidents i.e.injuries...significant behavioral changes to the Department and responsible parties within specified timeframes. This requirement was not met as evidence by;
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Administrator agrees to conduct a staff incident reporting training for all staff and administrators by 1/12/2026.
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Based on interviews the staff did not file an incident report of one of six persons in care which posed a potential Health and Safety risk to person in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230813115402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RENAISSANCE LIVING
FACILITY NUMBER: 374603906
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2026
Section Cited
CCR
87468(a)(1)
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Residents have the right to be treated with dignity in their relationships with staff and others.

This requirement was not met as evidence by;
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Administrator agrees to conduct a staff personal rights, dignity training for all staff and administrators by 1/12/2026.
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Based on interviews the staff did not show dignity to one of six persons in care which posed a potential Health and Safety risk to person in care.
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Type B
01/12/2026
Section Cited
CCR
87468(a)(3)
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Personal Rights: Residents have the right to be accorded respect and to be free from humiliation or abuse.

This requirement was not met as evidence by;
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Administrator agrees to conduct a staff personal rights training for all staff and administrators by 1/12/2026.
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Based on interviews the staff did not show respect to one of six persons in care which posed a potential Health and Safety risk to person in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5