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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701322
Report Date: 04/29/2024
Date Signed: 04/29/2024 03:29:47 PM


Document Has Been Signed on 04/29/2024 03:29 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:RENAISSANCE CARE HOME INCFACILITY NUMBER:
502701322
ADMINISTRATOR:RANIN, TERESITA N.FACILITY TYPE:
740
ADDRESS:812 NORWEGIAN AVENUETELEPHONE:
(505) 879-9212
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 5DATE:
04/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administraor Teresita RaninTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a pre-licensing inspection. LPA Lund met with Administrator Teresita Ranin and explained the purpose of the visit. Administrator Certificate Expires 11/29/2025. Census 5.

LPA Lund and Administrator Teresita Ranin toured/inspected the physical plant including the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, activity room, and outside courtyards. LPA Lund observed sufficient furniture and lighting throughout the facility. LPA Lund observed sufficient seven-day non-perishable and two- day perishable food supplies. Hot water temperature was measured at 108 degrees Fahrenheit in kitchen sink, which is within the required range of 105 to 120 degrees. Fire extinguishers expire 1/15/2025 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 2 resident and 2 staff files and were in compliance. Fire drill was completed on 4/1/2024. All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

No Deficiencies were during the visit. Exit interview with licensee and copy of the report left. LPA Lund conducted Component 111.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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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