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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600162
Report Date: 02/12/2025
Date Signed: 02/12/2025 11:04:53 AM

Document Has Been Signed on 02/12/2025 11:04 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:RENAISSANCE RESIDENTIAL CAREFACILITY NUMBER:
198600162
ADMINISTRATOR/
DIRECTOR:		RICARDO BANOSFACILITY TYPE:
740
ADDRESS:2537 ROYCROFTTELEPHONE:
(562) 961-9672
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 4DATE:
02/12/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:14 AM
MET WITH:Maria Tavarez TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On February 12, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced Case Management Continuation to complete inspection conducted on February 6, 2025 visit using the CARE Inspection Tools. LPAs met with Imelda Pascual explained the purpose of this visit. Subsequently, Administrator Maria Tavarez arrived to assist with the visit. The facility is licensed for (6) 60-year-old or older adults. May retain 1 hospice resident. Currently, there are 6 residents in the facility.

The facility is a single-story home located in a residential neighborhood which consists of the following: A living room, four (4) bedrooms, two (2) bathrooms, one (1) half-bathroom, dining room, kitchen, laundry area, detached garage, shaded area, indoor/outdoor activity areas.

Safety LPA observed and tested smoke/carbon monoxide combo detectors to be fully operable. LPA observed (2) fully charged fire extinguishers that was last serviced on 3/4/24 The last emergency drill was conducted on 2/11/25. LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, gauze, disinfectant wipes, band aids. LPA observed all exits to be clear and easily accessible. All toxins locked and inaccessible to residents in care.

Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet that is inaccessible to Residents in care.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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: 02/12/2025
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Files LPA reviewed ( 4 ) resident files and found that (4 ) out of (4 ) contained all the necessary documentation. LPA reviewed (4) staff files and found that (4 ) out of (4 ) contained the required documentation, certification, and training. Liability Insurance expires on 04/25/2025.

LPA observed that Annual licensing fee are current at this time. LPA reviewed facility contact information to insure that the information was current and accurate.

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff.

Outside area: During visit LPA observed the outside grounds (front and back) to be free of clutter, debris, and passage ways were free of obstruction.

There were no deficiencies cited during today’s visit. Exit interview conducted and copy of report provided to Administrator

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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