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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604105
Report Date: 11/21/2024
Date Signed: 11/25/2024 09:15:30 AM

Document Has Been Signed on 11/25/2024 09:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:RENAISSANCE LIVING IIFACILITY NUMBER:
374604105
ADMINISTRATOR/
DIRECTOR:		EDWARDS, RICHARDFACILITY TYPE:
740
ADDRESS:12536 JACKSON HILL LNTELEPHONE:
(619) 334-0143
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 6CENSUS: 5DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Unique MayTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Shelly Jenkins. Administrator Unique May arrived shortly after.

According to the facility’s license, the facility has a maximum capacity of 6 (six) elderly residents, age range over 60, six (6) of who may be non-ambulatory and 1 who may be bedridden. The facility is also approved for a hospice waiver for 4 residents. During today’s inspection, there were a total of 5 (five) residents present.

LPA, accompanied by Unique, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 76 degrees F. Hot water temperature at taps accessible to residents were all compliant: Bathroom #1 sink was 105.0 F, and Bathroom #2 had two sinks: sink #1 was 105.1 F and sink #2 was 105.3 F. Bathroom #3 was 105.7 F and Bathroom #4 was 105.9.

No pools or bodies of water were observed on the premises. Per Unique May, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. There were no sharp objects, toxic chemicals/poisons or open-faced heaters accessible to residents. There was a fireplace with a protector screen.

Medications were labeled, as required, and stored in locked areas. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 II
FACILITY NUMBER: 374604105
VISIT DATE: 11/21/2024
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[CONTINUED FROM LIC 809] LPA interviewed staff and residents. LPA reviewed staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. The Licensees also presented proof of current/active business liability insurance.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored in the kitchen. Cooking/dining equipment and utensils were present.

No citations were issued during this visit.

An exit interview was conducted Unique, and a copy of this report and Licensee/Appeal Rights (LIC 9058 03/22) were provided to her. Licensee’s signature below serves as acknowledgment of receipt of the documents.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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