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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700467
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:51:37 PM


Document Has Been Signed on 04/28/2022 12:51 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:RENAISSANCE CARE HOMEFACILITY NUMBER:
502700467
ADMINISTRATOR:RANIN, TERESITAFACILITY TYPE:
740
ADDRESS:812 NORWEGIAN AVETELEPHONE:
(505) 879-9212
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Teresita Ranin - AdministratorTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced 1 Year Required Annual Inspection Visit. LPA met with Administrator and explained the purpose of the visit. Administrator Certificate Expires 1128/2023.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. During the tour of the facility LPA observed removed addition to the facility's garage as staff quarters.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106.8 degrees Fahrenheit in kitchen sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers expire 1/21/2023 and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 6 resident and 4 staff files, including criminal record clearances. Fire drill was completed on 3/30/2022. All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete

No Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview with licensee and copy of the report with licensee..
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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