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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603906
Report Date: 01/11/2024
Date Signed: 01/31/2024 07:58:39 AM


Document Has Been Signed on 01/31/2024 07:58 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:RENAISSANCE LIVINGFACILITY NUMBER:
374603906
ADMINISTRATOR:RICHARD EDWARDSFACILITY TYPE:
740
ADDRESS:9112 WAKARUSA STREETTELEPHONE:
(619) 741-2499
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 6DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Caregiver Juana GutierrezTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Juana Gutierrez. Administrator Richard Edwards arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom may be non-ambulatory, three of which may be bedridden.

LPA toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils were present. Two days worth of perishable and seven days worth of non-perishable food was present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas.



No pools or bodies of water on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible.

Resident records reviewed had required documentation. Staff records reviewed contained required documentation.

No deficiencies were issued on today's visit.

An exit interview was conducted with Administrator Richard Edwards, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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