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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800083
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:09:58 PM

Document Has Been Signed on 01/16/2025 02:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:RENAISSANCE VILLAGE MURRIETAFACILITY NUMBER:
331800083
ADMINISTRATOR/
DIRECTOR:		BRIAN TAUBEFACILITY TYPE:
740
ADDRESS:24271 JACKSON AVENUETELEPHONE:
(951) 319-8243
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 166TOTAL ENROLLED CHILDREN: 0CENSUS: 95DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Senior Executive Director, Brian TaubeTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that ninety-five (95) residents live at this facility. The Executive Director, Brian Taube was advised of the annual and conducted and completed the facility tour, along with the Assistant Executive Director, Juan Vergara.

Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Brian Taube, Administrator’s certificate expiration date is 10/06/2025.



Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. The facility has food supplies delivered twice a week. Emergency food and water supply is present. There is a location for sharps in the kitchen.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Kathleen BanrasavongTELEPHONE: 951-622-3619
DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: RENAISSANCE VILLAGE MURRIETA
FACILITY NUMBER: 331800083
VISIT DATE: 01/16/2025
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Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. This facility is a three-story building. The Memory Care Unit is located in separate buildings. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the designated laundry rooms throughout the facility. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the housekeeper’s closet. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are zero (0) fireplaces at this facility. There are zero (0) pools at the facility. There is a secured perimeter surrounding the facility. LPA observed emergency supplies and several first aid kits, throughout the facility. During today's visit LPA tested the pull cord alert system located in room #105. LPA checked and verified the resident’s pull cord was functional and operational. The LPA did not test pull cords in the Memory Care Units due to the buildings not having any pull cords. LPA observed adequate staffing in the memory care units.

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff had infection control training.

Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: RENAISSANCE VILLAGE MURRIETA
FACILITY NUMBER: 331800083
VISIT DATE: 01/16/2025
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LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed dual smoke detectors and carbon monoxide detectors throughout the facility. There were several fire extinguishers throughout the facility, date charged was 07/05/2024. The latest fire inspection was conducted on 11/19/2024.

Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Executive Director, Brian Taube.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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