336426464-4-21-2023-18-AS-JDHS-D77VZN-20240715165301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426464
Report Date: 04/21/2023
Date Signed: 04/21/2023 01:20:47 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
11/04/2022 and conducted by Evaluator Stephanie Torres

COMPLAINT CONTROL NUMBER: 18-AS-20221104103618

FACILITY NAME:	MANZANITA VILLAGE AT 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:	04/21/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Denise Olson, Interim Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility hasn’t had a fire drill in the last 2 years
Insufficient staffing to meet residents' needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, arrived at the location, unannounced, in order to deliver the findings of the investigation into the above allegations. Due to the facility closing in February 2023, the LPA identified herself and discussed the purpose of the visit with the current Interim-Administrator, Denise Olson, of the presently licesned facility.

The investigation included staff/resident interviews, records review, and records collection.

A report was received by the Department alleging the facility has not had a fire drill in the last two years. Resident interviews could not corroborate or refute the validity of the allegation. Staff interviews revealed there have been fire drills in the memory care unit, though they were not conducted regularly due to the COVID-19 pandemic. Records were provided to show fire drills were conducted on October 09, 2022; September 09, 2022; August 09, 2022; and July 13, 2022. No other records were available for the year 2021 or the early months of the year 2022. Thereore, this allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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-20221104103618

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: MANZANITA VILLAGE AT RANCHO BELAGO	FACILITY NUMBER: 336426464
	VISIT DATE: 04/21/2023

NARRATIVE

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A report was also received alleging there was insufficient staffing to assist residents in being transferred from the dining room to their bedrooms following meals. Staff and resident interviews revealed there have been occasions when residents were left in the dining room, for thirty minutes to an hour, before being assisted to return to their bedrooms. Details, such as dates and circumstances, of such occasions could not be obtained from interviews. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

This report was reviewed with Olson and a copy was provided.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

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