502701322-4-30-2026-27-AS-NWPN-DTMVKS-20260430163048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701322
Report Date: 04/30/2026
Date Signed: 04/30/2026 04:31:00 PM

Document Has Been Signed on 04/30/2026 04:31 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 INC		FACILITY NUMBER:	502701322
ADMINISTRATOR/ DIRECTOR:	RANIN, TERESITA N.		FACILITY TYPE:	740
ADDRESS:	812 NORWEGIAN AVENUE		TELEPHONE:	(209) 408-8439
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY: 6		CENSUS: 5	DATE:	04/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Teresita Ranin		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unanounced to the facility to conduct an annual inspection 1:30pm on 4/30/26. LPA met with administrator Teresita Ranin, to explain the purpose of the visit. renaissance care home is a 6 bed facility with a current capacity of 6. theres 5 adults aged 60+ residing in the facility with 3 on hospice. LPA gave guidance that current fire clearance(6 nonambulatory, 6 hopice) would have to be updated to include bedridden should any of the clients present with the ability to not rotate themselves independently, unless the facility is assisting the resident with finding alternate housing. Physical inspection was conducted, including but not limited to kitchen, bedrooms, bathrooms, common areas, evacuation route and exterior. The facility is clean, traffic areas are well lit and unobstructed. kitchen has adequate lockable storage for sharps. there is food storage adequate for 2 days perishable, 7 days non perishable for 5 residents eating 3 meals and 3 snacks a day. The LPA asked for foods being stored without a label of expiration(i.e. leftovers) to be dated. freezer stored items should be inspected quarterly for frost damage. Bedrooms have the required furniture and furnishings. Bathrooms have functional hardware, and have temperature measured between 105 and 120*F. Common areas and exteriors are free of tripping hazards and have furniture in good repair. The evacuation route gate is not able to swing freely and latch closed. LPA gave guidance the gate should be shaved down or rehung. The Fire extinguishers are dated January 2026, the first aid kit has all required items, and the smoke/co detector is functional. 2 staff and 2 clients were interviewed. continued on c page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RENAISSANCE CARE HOME INC	FACILITY NUMBER: 502701322
	VISIT DATE: 04/30/2026

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5 of 5 Staff files including health screening, continuing and initial trainings, cpr/first aid certification and backround checks are present and up to date. 2 of 2 Client files including the signed admission agreements, addendums to the admission agreement, recent 602 medical asseessment and needs and services plans were up to date and present. Administrator files, including but not limited to facilitiy posters, insurances, control of the property, evacuation plan, and infection control plan were reviewed, and found to be present and up to date.

PRN documentation is not being filled out completely as described in regulation and cold storage medication was not locked, LPA gave guidance for the administrator that her 20 hours per week should have some time devoted to assessing each of the staff on the policies and procedures of their regular duties.

No citations given as part of this visit, a copy of the report was read and given to the administrator. exit interview conducted. LPA asked for a updated LIC 500 and LIC 9020 to be emailed to the LPA, noel.wolfpetersen@dss.ca.gov

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

LIC809 (FAS) - (06/04)

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