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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604105
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:06:07 PM

Unsubstantiated


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
01/30/2023 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20230130081739
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: 4DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Silvia Moreno CamachoTIME COMPLETED:
02:18 PM
ALLEGATION(S):
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-Resident received unexplained injuries in care
-Staff yelled at residents
-Staff did not follow food preparation requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Caregiver Silvia Moreno Camacho and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA interviews with residents and facility staff and records review.

It was reported to CCL that Resident (R1) received unexplained injuries while in care.[an LIC 811 Confidential Names List was provided to the facility representative to identify the resident.]. Complainant also reported that a staff member; Staff #1 (S1) yelled at R1 and other residents. S1 was also reported to be handling chemicals (insect spray near the area food is prepared for the residents.) Interview with Staff #2 (S2) revealed no knowledge of any staff members yelling or acting aggressively towards residents. S2 further stated that one ex-staff member (S1) was a foreigner and would speak louder due to an accent and cultural differences.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
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 3
Control Number 08-AS-20230130081739
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: 04/27/2023
NARRATIVE
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S2 went onto say that this ex-staff member (S1) was loved by all of the residents and their responsible parties due to the staff's warm demeanor and family style meals they would regularly cook for the residents. S2 further stated that they have never used or seen another staff member spray insect chemicals inside the facility, primarily because a pest control company regularly visited the facility.

Interview with R1 revealed no issues with staff members at the facility. R1 stated that they did not recall ever being yelled at or physically abused at the facility.

Interview with Resident 2 (R2) revealed no issues with any staff members. R2 further stated that they have never been verbally or physically abused by any staff member at the facility.

Interview with Outside Agency (OA) revealed that they worked closely with R1. OA stated R1 has a medical condition which causes R1 to fall down randomly, which often resulted in bruising on the knees and legs. OA stated that they never witnessed nor had any suspicion that S1 hit or injured R1. OA further stated that S1 often spoke in a loud and animated manner due to a cultural difference which could be confused for yelling. OA stated that they never witnessed staff using any insect chemicals inside the facility but they have witnessed a pest control company working at the facility.

Interview with Administrator revealed no knowledge of any residents or family members upset with a staff member at the facility. Administrator stated that they and R1's responsible party would be in regular contact via text message. Administrator stated that they were never advised of any issues with the facility or a staff member. Administrator stated that it was in fact the opposite in that R1's responsible party would praise them (via text) for the work they did with R1. Administrator stated that R1 initially left the facility to live with the their Responsible Party on November 2022. Administrator stated that after a brief stay at the Responsible Party's residence they attempted to move R1 back to Renaissance Living II in the beginning of December 2022, but it was not possible since the room was already occupied. Administrator further stated that the facility had a contract with Aptive pest control company for several years and their would be no need for any insect chemicals to be used or stored inside of the facility.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230130081739
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: 04/27/2023
NARRATIVE
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Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid.

An exit interview was conducted with Silvia Moreno Camacho and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Silvia Moreno Camacho whose signature below confirms receipt of documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3