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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881349
Report Date: 07/11/2024
Date Signed: 07/11/2024 04:23:20 PM


Document Has Been Signed on 07/11/2024 04:23 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: 83DATE:
07/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Brooke Abrego Huerta, Executive DirectorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to follow up on two incident reports received from the facility relating to alleged theft.

The Department received two reports relating to the theft of personal items belonging to Resident One (R1). During the visit the LPA reviewed and collected relevant records. Additional time is required, prior to the conclusion of the investigation, in order to obtain further information.

This report was reviewed with the Executive Director and a copy provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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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