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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426464
Report Date: 05/19/2021
Date Signed: 05/19/2021 03:54:47 PM

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 RANCHO BELAGOFACILITY NUMBER:
336426464
ADMINISTRATOR:EREBHOLO, LATONYAFACILITY TYPE:
740
ADDRESS:27900 BRODIAEA AVE.TELEPHONE:
(800) 870-8066
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:125CENSUS: 56DATE:
05/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:LaTonya ErebholoTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jennifer Semin arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20210518113609 to check on the health, safety, and welfare of residents in care. LPA met with administrator LaTonya Erebholo and explained the purpose of the visit. LPA was informed that fifty six (56) residents currently reside at this facility. There were eight (8) direct care staff on duty during the time of the visit.

During the visit, LPA toured the inside and outside of the facility. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. LPA observed all facility utilities to be on and operating without issue. LPA also observed a live musician playing for residents during a happy hour activity.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit.

An exit interview was conducted and a copy of this report was provided to Administrator Ms. Erebholo.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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