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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602161
Report Date: 05/19/2026
Date Signed: 05/19/2026 03:06:22 PM

Document Has Been Signed on 05/19/2026 03:06 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PDM RENAISSANCE HOMEFACILITY NUMBER:
198602161
ADMINISTRATOR/
DIRECTOR:		GONZALES, LUIS SFACILITY TYPE:
735
ADDRESS:11451 178TH STTELEPHONE:
(562) 924-2957
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 3DATE:
05/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Administrator TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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On 5/19/2026, Licensing Program Analyst(s) (LPA) Jewel Baptiste conducted an unannounced annual visit at PDM Renaissance Home, using the CARE tool. LPA Baptiste met with DSP Winda Yambao and explained the reason for the visit. Administrator Archimedes Lopez and Mirafy Lope zarrived at 1:00 p.m. and further assisted with the visit.

This home is licensed to serve (4) Developmentally Disabled Adults, (4) non-Ambulatory and (1) maybe bedridden. The clients served are between the ages of 18 through 59 with 1 hospice wavier, vendorized by Harbor Regional Center. There were (3) clients in care during the time of this visit. LPA was unable to interview the clients (2) due to limited communication. The last emergency disaster/fire drill was conducted on 5/05/2026. The Administrator Certificate expires on 8/19/2027. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (3) client files, medications, and medication administration records for (3) clients and P&I.The facility is a single story home, located in a residential area. It consists of 3-client bedrooms, 2-bathrooms, 1 living room, 1 dining with covered fireplace, office, kitchen, a detached garage, a front yard and backyard.

Report continued 809C

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PDM RENAISSANCE HOME
FACILITY NUMBER: 198602161
VISIT DATE: 05/19/2026
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LPA Baptiste conducted a tour of the facility with Administrator Mira and observed the following: Facility is clean and in good repair indoors and outdoors. Kitchen is clean, sharps were locked and inaccessible to clients. Fire extinguisher observed in the kitchen and dining room. The cleaning supplies were locked in a kitchen cabinet. Sufficient food supplies were observed, at least 2 days of perishables and 7 days of non-perishables. (3) client's bedrooms were observed with sufficient lighting, furniture, and bedding supplies. (2) client bathrooms were observed in working conditions with grab bars, and skid mats. The water temperature was tested between 116.1 -116.2, which is within the required 105-120 degrees F. The dining room and living room were observed with sufficient sitting area. Smoke/Carbon monoxide detectors were tested and in working condition. The garage contained another room with sitting area and storage supplies, PPE’s, water, and toiletries. The backyard and front yard were observed with covered sitting area.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview was held and a copy of the report was provided to the Administrators.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC809 (FAS) - (06/04)
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