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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426464
Report Date: 03/08/2021
Date Signed: 03/09/2021 09:44:50 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2021 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210112131048
FACILITY NAME:RENAISSANCE VILLAGE RANCHO BELAGOFACILITY NUMBER:
336426464
ADMINISTRATOR:EREBHOLO, LATONYAFACILITY TYPE:
740
ADDRESS:27900 BRODIAEA AVE.TELEPHONE:
(800) 870-8066
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:125CENSUS: 54DATE:
03/08/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LaTonya ErebholoTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Tap in resident's room does not heat to a temperature sufficient for bathing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jennifer Semin called the facility for the purpose of delivering findings for the above allegation. LPA spoke with LaTonya Erebholo.
The above complaint was investigated by the department. The investigation consisted of interviews with staff, resident and reporting party that were conducted via telephone and observations conducted via FaceTime due to Covid-19.
Based on a review of information gathered from documentation, and interviews, LPA was unable to corroborate the allegation. The reporting party stated it was taking 10 minutes or more for the water temperature to reach 105-120 degrees F. Facility staff stated the water takes less than 3 minutes to reach 105-120 degrees F. LPA observed the water taking approximately 30 seconds to reach 105-120 degrees F via FaceTime. Resident 1 (R1) did not recall having trouble with the water not getting hot.
The department has investigated this complaint and found the allegation to be UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of this report was provided to Ms. Erebholo via email. Report with facility representative signature was obtained.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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