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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881349
Report Date: 01/27/2023
Date Signed: 01/27/2023 05:36:07 PM


Document Has Been Signed on 01/27/2023 05:36 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MANZANITA VILLAGE AT RANCHO BELAGOFACILITY NUMBER:
331881349
ADMINISTRATOR:TAYLOR, KAMESHIFACILITY TYPE:
740
ADDRESS:27900 BRODIAEA AVENUETELEPHONE:
(503) 392-9999
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:125CENSUS: 67DATE:
01/27/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Executive Director, Kameshi TaylorTIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an announced visit to the facility in order to conduct a pre licensing inspection. LPA met with the Executive Director, Kameshi Taylor who was informed of the purpose of the visit. The applicant is seeking to do a change in ownership and serve as a residential facility for the elderly. Population to be served is ages 60 and above.

LPA conducted a tour of the interior and exterior of the facility. LPA observed the home to be a (3) building one-story structure with capacity for 125 residents. There is (1) main building for Assisted Living, and (2) buildings for memory care . LPA reviewed the fire clearance for the facility completed on 12/22/2022 by Moreno Valley Fire Department granting clearance for (113) non ambulatory and (12) bedridden residents. LPA observed the emergency exits to be free of obstructions. LPA observed resident bedrooms contained the required furniture and linens along with private bathrooms having running water and required accommodations. LPA observed the resident restroom to have non-slip material. The fire alarms and carbon monoxide detector was tested and operational. LPA observed the kitchen to have the required perishable and non-perishable food supplies. The kitchen also possesses enough cooking supplies and utensils, cleaning supplies, and safety equipment. LPA observed the (3) medication med carts, and observed where the cleaning chemicals will be stored locked. LPA observed the laundry equipment to be functional, as well as all other utilities. The hot water temperature was recorded at 107.7F. The facility has a land line at : (951) 379-0100 which was observed to be operational. LPA reviewed the facility's emergency and disaster plan, and the administrator's certificate was current with expiration date 4/9/2024.

NO fire arms or bodies of water are present at the facility. Component III presentation was completed during the time of the visit.

An exit interview was conducted where this report was reviewed and provided to, Executive Director Kameshi Taylor.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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