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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604105
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:18:21 PM

Document Has Been Signed on 08/20/2021 03:18 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 IIFACILITY NUMBER:
374604105
ADMINISTRATOR:EDWARDS, RICHARDFACILITY TYPE:
740
ADDRESS:12536 JACKSON HILL LNTELEPHONE:
(619) 334-0143
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 6CENSUS: 6DATE:
08/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee, Richard EdwardsTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA), Alexandre Vo, conducted a case management deficiency found during a complaint investigation. LPA met with Licensee, Richard Edwards, and explained the purpose the case management.

The Department’s findings were derived from records and interviews surrounding charges against a former resident’s account that were not agreed upon.

During the complaint investigation, financial ledgers show that Resident #1 and Resident #2 were charged a household moving fee of $1,800, as well as, a $475 outside auditor fee. Based on interviews and review documents, neither charges were agreed upon by the residents. Therefore, the Department concludes that the licensee did not adhere to the payment provisions in the residents’ admission agreements. Therefore, the resident, or their representative, is owed $2275.00.

In addition, the conflicting language of the facility’s admission agreement indicates that “pre-admission fees are not charged. If in the future a preadmission fee is charged, the admission agreement will be revised…” Records review indicate that residents, R1 through R6, were charged the pre-admission fee of $500.00 each and their admission agreements were not revised to reflect the appropriate charge and refund conditions.

Based on evidence gathered during the complaint investigation, the accounting for unsettled funds resulted in an owed amount of $7,711.05.

The total refund due to residents R1 and R2, or their representative, is $10,986.05 -- preadmission and unsettled funds. The amount owed to each resident R3, R4, R5, and R6 is $500.00 each.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alexandre Vo
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2021 03:18 PM - It Cannot Be Edited


Created By: Alexandre Vo On 08/19/2021 at 02:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
09/10/2021
Section Cited
CCR
87507(g)(3)(B)(2)

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87507 Admission Agreements (g) Admission agreements shall specify the following (3)...(B) Rate for additional items and services, including: 2. A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement.
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The licensee agreed to refund R1 and R2, or their responsible party, in the amount of $2275.00 and $7,711.05. Licensee agreed to provide proof payment by cancelled check or similar to LPA by the POC date.
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This requirement was not met as evidenced by: Based on records and interviews, the licensee charged resident #1 for a service that was not included and authorized by the admission agreement. This posed a potential financial risk to the resident in care.
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Type B
09/10/2021
Section Cited
CCR87507(a)(1)(B)

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87507 Admission Agreements (a) … (1) The text of the admission agreement, including any attachments and modifications, shall be: (B) Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled.
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The licensee agreed to refund the resident, or their responsible party, in the amount of $500.00 for R1, R2, R3, R4, R5, and R6. Licensee agreed to provide proof of payment or similar to LPA by POC date.
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This requirement was not met as evidenced by: Based on records review and interviews, the admission agreements for six out of seven residents contain ambiguous language regarding pre-admission fees. This posed a potential financial risk to all residents in care.
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In addition, the licensee agreed to update their admission agreement for all current residents, and provide an admission agreement addendum to LPA by POC date.
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
LICENSING EVALUATOR NAME:Alexandre Vo
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


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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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Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, Chapter 8 and are listed on the LIC809D. A Plan of Correction was developed with the Licensee. An exit interview was conducted, and a copy of this report, List of Confidential Names, and Licensee’s Rights (9058 01/16) were provided to the Licensee, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alexandre Vo
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
LIC809 (FAS) - (06/04)
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