331800166-9-21-2023-18-AS-SMAZ-CVVRMV-20230921130923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800166
Report Date: 09/21/2023
Date Signed: 09/21/2023 01:09:28 PM

Document Has Been Signed on 09/21/2023 01:09 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	RANCHO BELAGO RESIDENTIAL CARE		FACILITY NUMBER:	331800166
ADMINISTRATOR:	KHAN, MUSARRAT		FACILITY TYPE:	740
ADDRESS:	13816 NATHAN PLACE		TELEPHONE:	(951) 242-8875
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	6	CENSUS: 4	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:32 AM
MET WITH:	Saleem Ansari - Staff		TIME COMPLETED:	01:18 PM

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with staff Saleem Ansari, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and four (4) residents present.

The facility is a one story home with (4) bedrooms and (3) bathrooms with an attached garage, and a backyard. The residents served are elderly adults sixty-five (65) years of age and older. The facility does not have any bodies of water, firearms, or ammunition on the property. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed staff records and found that all staff had infection control training.

Physical Plant: LPA observed the resident bedrooms, bathrooms, and staff room. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational and the hot water temperature 110 F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RANCHO BELAGO RESIDENTIAL CARE	FACILITY NUMBER: 331800166
	VISIT DATE: 09/21/2023

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Care & Supervision/Administration: Adequate staff are present for the supervision of residents during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed three (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Four (4) resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: Resident medication was locked in a cabinet located in the dining room area. LPA reviewed medications for four (4) residents and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility conducts fire and earthquake drills throughout the year which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

An exit interview was conducted where a copy of this report was provided to staff Saleem Ansari.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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