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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881349
Report Date: 03/08/2024
Date Signed: 03/08/2024 04:11:01 PM


Document Has Been Signed on 03/08/2024 04:11 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 ASC, 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:
(951) 379-0100
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:125CENSUS: 76DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Brooke Abrego Huerta, AdministratorTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility to conduct a required annual inspection. The LPA met with Administrator, Brooke Abrego Huerta, and informed her of the purpose for the visit.

Staff Interviews: Interviews were conducted with facility care staff. Staff displayed sufficient knowledge and awareness in providing appropriate care and supervision to residents.

Emergency Disaster Plan: The Emergency Disaster Plan was reviewed. The plan was observed to require updates, as the plan indicates an emergency generator is available for use; however, according to one staff interview the facility has no generator on the premises. According to the Maintenance Director, contact information is available for a company who can provide an emergency generator. According to Administrator Huerta, the plan was last reviewed January 2024.

Due to insufficient time a return visit will be conducted in order to complete the inspection.

This report was reviewed with Administrator, Brooke Abrego Huerta, and a copy was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
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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