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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604442
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:16:53 AM

Unsubstantiated


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
07/19/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230719160855
FACILITY NAME:RENAISSANCE LIVING IIIFACILITY NUMBER:
374604442
ADMINISTRATOR:EDWARDS, RICHARDFACILITY TYPE:
740
ADDRESS:423 AVOCADO AVETELEPHONE:
(619) 954-0963
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:6CENSUS: 6DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Ann Nicholas, CaregiverTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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Staff physically abused resident resulting in injury
Staff verbally abused resident
Facility did not have sufficient food
Facility was not maintained in clean condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings on the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Caregiver Ann Nicholas.

On July 19, 2023, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) was physically abused by Staff 1 (S1), multiple residents were verbally abused by Staff 2 (S2), facility did not have sufficient food for all the residents and facility was not maintained in clean condition. During the investigation, LPA Strong conducted interviews, a facility inspection, and reviewed facility records.

According to allegations, on an unidentified date, R1 was hit by S1 causing bruises to mouth and shoulder. Interviews with an outside source revealed that R1 has a continuous mouth sore that appear as if it were a bruise. Outside source also revealed that R1 tends to flail in their wheelchair causing bruises throughout their body. Interview with S1 revealed that they do not work at this facility often and have not worked there in more than four months.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 2
Control Number 08-AS-20230719160855
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 III
FACILITY NUMBER: 374604442
VISIT DATE: 08/31/2023
NARRATIVE
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Interview with Administrator revealed that there have been no reported incidents to them regarding staff being physically abusive to any resident.

It was also alleged that S2 yells at residents. Interviews with residents revealed no instances where any of the staff have yelled at the residents. Interview with outside source revealed they are present at the facility multiple times per week and have not witnessed any incidents of staff yelling at residents. Interview with Administrator revealed that there have been no reported incidents to them regarding staff being verbally abusive to any resident.

Additionally, it was alleged that facility does not have sufficient food for residents. LPA Strong conducted a facility inspection on July 26, 2023. On this date LPA observed full dry pantry with multiple snacks and dry food. LPA also observed refrigerator with fresh fruits, vegetables, and meats. Interview with outside source revealed that residents are given enough food based on their diets and ability to eat. Interview with multiple staff revealed that staff prepare numerous meals per day made from scratch for all the residents. Interview with Administrator revealed that if any food items are needed urgently, then the Administrator will conduct an immediate visit to the grocery store or request the item via Instacart delivery.

Lastly, it was alleged that facility is only cleaned with water and cleaning supplies are not provided. On July 26, 2023, LPA Strong conducted a facility inspection. On this date, LPA Strong observed multiple cleaning supplies including disinfecting wipes, bleach and other cleaning agents. Interview with outside source revealed facility is always clean and there have never been any instances where the facility had any foul odors. Interview with Administrator revealed that cleaning supplies are purchased often at bulk stores to maintain large portions available at the facility.

Based on LPA's interviews, inspection and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Caregiver Ann Nicholas to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2