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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
374604442
Report Date:
08/22/2024
Date Signed:
08/22/2024 02:19:29 PM
Document Has Been Signed on
08/22/2024 02:19 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
SAN DIEGO RO
,
7575 METROPOLITAN DR. #109
SAN DIEGO
,
CA
92108
FACILITY NAME:
RENAISSANCE LIVING III
FACILITY NUMBER:
374604442
ADMINISTRATOR/
DIRECTOR:
EDWARDS, RICHARD
FACILITY TYPE:
740
ADDRESS:
423 AVOCADO AVE
TELEPHONE:
(619) 954-0963
CITY:
EL CAJON
STATE:
CA
ZIP CODE:
92020
CAPACITY:
6
CENSUS:
5
DATE:
08/22/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:16 PM
MET WITH:
Unique Maye, Administrator
TIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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LPA Hall at the facility to AMEND 9099D from June 18, 2024 with the correct policy citation as
Health and Safety Code1569.652 (c)
Plan of Correction has been completed.
SUPERVISORS NAME
:
Denise Powell
LICENSING EVALUATOR NAME
:
Renita Hall
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/22/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/22/2024
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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