336426464-5-9-2023-18-AS-EMAN-CRUMPT-20230515094740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426464
Report Date: 05/09/2023
Date Signed: 05/09/2023 12:23:40 PM

Unsubstantiated

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
05/18/2021 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210518113609

FACILITY NAME:	RENAISSANCE VILLAGE RANCHO BELAGO		FACILITY NUMBER:	336426464
ADMINISTRATOR:	EREBHOLO, LATONYA		FACILITY TYPE:	740
ADDRESS:	27900 BRODIAEA AVE.		TELEPHONE:	(800) 870-8066
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	0	CENSUS: 0	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	11:32 AM
MET WITH:	Brian Taube-Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff caused bruising to resident.
Facility staff handled resident in a rough manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility to deliver findings for the above complaint allegations. LPA met with Executive Director Brian Taube and explained the reason for the visit. During a visit on 3/14/23, LPA discovered that the facility is under new ownership, changed their name, and has mostly new staffing.

The investigation was initiated in 5/19/2021 which consisted of interviews and file review revealed the following:

For allegation, Facility staff caused bruising to resident:

It was alleged that staff S1 caused bruising to R1 while in care.

During a visit on 3/14/23, LPA attempted to interview S1 and R1. S1 does not work at the facility as of December 2022 and their whereabouts are unknown.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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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Control Number 18-AS-20210518113609

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RENAISSANCE VILLAGE RANCHO BELAGO	FACILITY NUMBER: 336426464
	VISIT DATE: 05/09/2023

NARRATIVE

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LPA attempted a phone call to S1, but their last known phone number has been disconnected. R1 passed away in January of 2023.

During interview with R1’s spouse, R1’s spouse did not recall bruising being caused to R1 by S1 or by any other staff.

During interviews with staff, staff could not recall if R1 had bruises around the time of the complaint. Staff stated that S1 was not seen by staff handling residents in a way that would cause injury. Staff stated they are trained to be gentle when handling the residents.

During interviews with residents, the residents did not recall S1 working at the facility and stated they have not been injured and or bruised by any other staff.

During document review, LPA discovered a document sent to a medical provider detailing R1’s bruising on 5/15/2021, but the document does not state how the bruising occurred. The document states the location of the bruising on the body and that they would continue to monitor the bruising.

For allegation, Facility staff handled resident in a rough manner:

It was alleged that staff S1 handled R1 in a rough manner causing bruising.

During a visit on 3/14/23, LPA attempted to interview S1 and R1. S1 does not work at the facility as of December 2022 and their whereabouts are unknown. LPA attempted a phone call to S1, but their last known phone number has been disconnected. R1 passed away in January of 2023.

During interviews with staff, LPA was not given information that S1 handled R1 in a rough manner. Staff stated they are trained to be gentle when handling the residents.

During interviews with residents, LPA was not given information that the residents were handled rough by S1 or any other staff. The residents all had good things to say about the care and handling provided to them by the staff.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20210518113609

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RENAISSANCE VILLAGE RANCHO BELAGO	FACILITY NUMBER: 336426464
	VISIT DATE: 05/09/2023

NARRATIVE

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Based on the evidence found during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Executive Director Brian Taube, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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