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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600162
Report Date: 02/10/2022
Date Signed: 02/10/2022 01:47:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:RENAISSANCE RESIDENTIAL CAREFACILITY NUMBER:
198600162
ADMINISTRATOR:RICARDO BANOSFACILITY TYPE:
740
ADDRESS:2537 ROYCROFTTELEPHONE:
(562) 961-9672
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:TIME COMPLETED:
01:45 PM
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On 02/10/22 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced Annual Inspection, with an emphasis on Infection control. LPA met with caregiver Imelda Castelo, and the purpose of the visit was explained. LPA was screen for Covid-19 symptoms, and temperature was documented. The facility is vendorized with Harbor Regional Center and it's licensed for six (6) non-ambulatory resident are age 60 and above. Currently there are three (3) residents live in the facility

The facility is four bedrooms, three bathrooms, living room, dining area, kitchen, family room, live in staff room, laundry room and covered patio with adequate tables and chairs. There's no bodies of water on the premises. All outdoor and indoor passageways are free of obstruction. All bedrooms are for the non-ambulatory residents. All bedrooms have a bed, chair, night stand, closet and adequate lighting. All bathrooms are accommodated for the non-ambulatory residents in a wheelchair.
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. All bathrooms have a working toilet, wash basin and shower. Required Postings, including indoor and outdoor sign's regarding Covid-19, and good hand hygiene were visible, and posted. Dishes, cups and flat ware are stored in the kitchen cabinet, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are locked under the sink. Food supply adequate stored in the kitchen and consists of the following: 2 days perishable and 7 days non-perishable.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: RENAISSANCE RESIDENTIAL CARE
FACILITY NUMBER: 198600162
VISIT DATE: 02/10/2022
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The smoke detectors are in each bedroom and common area and they are all interconnected and operational. The carbon monoxide detectors located in the living room and it's operational. The last fire drill was conducted on 02/02/22. Refrigerator, Stove burners, oven, microwave, washer, and dryer were observed, and are all working properly. All the cleaning solutions are locked and stored in the cabinet in the laundry room and are inaccessible to clients. The hot water measured at in 118.degrees which is under Title 22 regulations, or 105D-120D. Adequate supply of linen stored in the hallway cabinet. LPA observed both residents and staff record stored in the locked cabinet next to the dining table. LPA inspected two (2) residents files, all the residents has an updated physician report, TB test result, IPP and admission agreement. LPA inspected two (2) Staff files and they all have updated training requirement, first aid certificate and health screening and TB test result. The administrator is Maria Tavarez and her administrator certificate expired on 08/23.
LPA observed over the minimum of 30 day supply of PPE’s which include: Face Shields, Gowns, N95, surgical masks. Technical Advisory was given for N95 Fit testing for staff.

An Exit interview conducted and a copy of the report was provided. No citations were issued during this visit.


SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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