198600162-1-31-2024-11-AS-MLEN-D2239D-20240131170258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600162
Report Date: 01/31/2024
Date Signed: 01/31/2024 05:03:05 PM

Document Has Been Signed on 01/31/2024 05:03 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	RENAISSANCE RESIDENTIAL CARE		FACILITY NUMBER:	198600162
ADMINISTRATOR:	RICARDO BANOS		FACILITY TYPE:	740
ADDRESS:	2537 ROYCROFT		TELEPHONE:	5629619672
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 4	DATE:	01/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:17 PM
MET WITH:	Maria Tavarez, Administrator		TIME COMPLETED:	05:13 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/31/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by Administrator, Maria Tavarez, to explain the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory residents ages 60 and over and has an approved hospice waiver for two (2) residents. The facility is a single story, 5 bedrooms which 4 bedrooms are for residents and 1 bedroom is for live-in staff, 2 common restrooms, 1 private restroom, one (1) laundry room, dining area, living room with staff computer, kitchen, pantry, linen closet, a designated outdoor shaded area and a detached garage that stores a freezer and additional food, paper and hygiene products. The facility water temperatures measured between 105 and 118 degrees F. The facility has a working landline telephone. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. Resident rooms were inspected, beds and bedding supplies were in good condition and adequate lighting was provided. Adequate storage, for the client's personal belongings, was observed. Bed linens, comforters, and bath towels were adequately stocked during the visit. All bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be mostly sanitary and appropriately furnished at the time of visit. LPA observed the Southern facing screen, located in the kitchen, is in disrepair and needs to be re-screened, see LIC809D. All storage areas for personal hygiene, toxins, and sharp objects were stored and not accessible to residents. LPA observed one cleaning product left accessible in the laundry room, see LIC9102TV. LPA reviewed Medication Administration Records (MAR) which revealed to be accurate and maintained in order. The kitchen was inspected and sufficient perishable and non-perishable food was maintained adequately. One (1) fire extinguisher was charged as of 03/09/23. Smoke detectors and carbon monoxide were in working condition and the last fire drill was conducted on 01/03/24. Report continues, see LIC809C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: RENAISSANCE RESIDENTIAL CARE	FACILITY NUMBER: 198600162
	VISIT DATE: 01/31/2024

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed there were screening protocols for visitors, staff, and residents, sanitizing stations with paper towels in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan.
LPA observed the facilities' Surety Bond, validated through Rimkin Co, Inc., provided on 06/30/23 which covers $2,000 per instance. LPA also observed property insurance, validated through Rimkin Co, Inc.
There was one (1) deficiency cited during today's inspection and a plan of corrections were created with Administrator, Maria Tavarez. See LIC809D.
There was one (1) technical violation note provided during today's inspection and a copy was provided to Administrator, Maria Tavarez. See LIC9102TV.

An exit interview was conducted with Administrator, Maria Tavarez. One (1) deficiency LIC809D, one (1) LIC9102TV, and a copy of the appeal rights and this report were provided to Administrator, Maria Tavarez.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/31/2024 05:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: RENAISSANCE RESIDENTIAL CARE	FACILITY NUMBER: 198600162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in the southern facing wall's window screen in disrepair, located in the kitchen, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	LPA and Administrator have agreed that Administrator or Licensee will forward images of the repaired screen, via email at MARIO.LEON@DSS.CA.GOV, on or prior to the POC due date which is 02/21/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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