<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800083
Report Date: 07/26/2022
Date Signed: 07/26/2022 02:16:17 PM


Document Has Been Signed on 07/26/2022 02:16 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:RENAISSANCE VILLAGE MURRIETAFACILITY NUMBER:
331800083
ADMINISTRATOR:BRIAN TAUBEFACILITY TYPE:
740
ADDRESS:24271 JACKSON AVENUETELEPHONE:
(951) 319-8243
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:166CENSUS: 76DATE:
07/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:EXECUTIVE DIRECTOR BRAIN TAUBETIME COMPLETED:
01:55 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 07/26/2022, Licensing Program Analyst (LPA), Venus Mixson made an unannounced case management visit to the above facility for the purpose of investigating a recent death. LPA Mixson met with Executive Director Brian Taube, who was informed of the purpose of the visit.

There were 76 clients and 60 staff at the time of the visit. LPA Mixson requested pertinent documents related to Client 1 (C1)'s death. LPA Mixson interviewed Executive Director and Wellness Director.

LPA received pertinentt documents.

LPA reviewed death report that was submitted by Wellness Director, Silvia Anaya to the Department on 07/25/2022. LPA will issue deficiency for reporting requirements.



An exit interview was conducted. A copy of this report along with the 809 D, LIC 811, and the appeals rights was given to the Executive Director.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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 3


Document Has Been Signed on 07/26/2022 02:16 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: RENAISSANCE VILLAGE MURRIETA
FACILITY NUMBER: 331800083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited

1
2
3
4
5
6
7
87211 (a)(1)(A) Reporting Requirments
Each licensee shall furnish to the licensing ageny a written report for the death of any resident within seven days of occurrence.
This was not met as evidence by:
Facility failed to report to the Department within the required time the death of (R1).

1
2
3
4
5
6
7

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: RENAISSANCE VILLAGE MURRIETA
FACILITY NUMBER: 331800083
VISIT DATE: 07/26/2022
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
26
27
28
29
30
31
32
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3