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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881349
Report Date: 09/10/2024
Date Signed: 09/10/2024 05:00:33 PM


Document Has Been Signed on 09/10/2024 05:00 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:
(951) 379-0100
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:125CENSUS: 84DATE:
09/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Brooke Abrego-Huerta, Executive Director & Anna Martinez, Memory Care DirectorTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced Case Management Death Report visit. LPA was greeted by Brooke Abrego-Huerta, Executive Director. LPA explained the purpose of the visit. The visit is in response to the death of Resident #1 (R1), that was reported on 09/09/2024 to have died of unknown cause on 09/07/2024.

During LPA's visit, LPA reviewed R1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's report, Appraisal/Needs and Services Plan, physician's orders, POLST, Medication list, three (3) statements and email notifications to CCLD. LPA also requested a copy of R1s death certificate when it is made available, and staff schedule for 9/6/2024 and 9/7/2024.

During today's visit no deficiencies were cited.

An exit interview was conducted, and a copy of this report was provided to Brooke Abrego-Huerta along with a copy of the LIC811.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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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