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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602161
Report Date: 05/30/2024
Date Signed: 05/30/2024 04:17:50 PM

Document Has Been Signed on 05/30/2024 04:17 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PDM RENAISSANCE HOMEFACILITY NUMBER:
198602161
ADMINISTRATOR/
DIRECTOR:		GONZALES, LUIS SFACILITY TYPE:
735
ADDRESS:11451 178TH STTELEPHONE:
(562) 924-2957
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 3DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:33 PM
MET WITH:Administrator Archi Lopez TIME VISIT/
INSPECTION COMPLETED:
04:32 PM
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On 5/30/24 at 2:33 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to PDM Renaissance Home. Upon arrival LPA was greeted by Direct Support Professional (DSP) Susan Robles who contacted the Administrator, Archimedes Lopez. The Administrators Archi and Mira Lopez arrived at 2:40 p.m., to assist with today's visit. Licensee/Administrator Mary Gonzales and Administrator also joined the visit. This home is licensed to serve (4) Developmentally Disabled Adults, (4) non-Ambulatory and (1) maybe bedridden. The clients served are between the age of 18 through 59 with 1 hospice wavier, vendorized by Harbor Regional Center. There were (3) clients in care during the time of this visit. LPA was unable to interview the clients due to limited communication. The last emergency disaster/fire drill was conducted 3/24/2024. The Administrator Certificate expires on 08/20/2025 #6003934740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (3) client files, medications, and medication administration records for (3) clients and P&I.

This home contains 3 bedrooms, 1 staff bathroom, 1 resident bathroom, living room, office, kitchen, dining room, activities room with covered fireplace, laundry room and a detached garage with extra room. LPA toured the physical plant with the Administrator. and observed all (3) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and skid matts. The temperature measured at 105.9*F. The smoke detectors were battery operated and tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in kitchen and dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The knives were secured in kitchen cabinet. The cleaning agents and toxins were also locked in a kitchen.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PDM RENAISSANCE HOME
FACILITY NUMBER: 198602161
VISIT DATE: 05/30/2024
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The pantry was well stocked with canned goods, pasta, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.

The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage and the extra room contained storage and seating area.

Exit interview conducted with Mira Lopez, Archi Lopez and Mary Gonzales, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
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