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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426464
Report Date: 11/17/2021
Date Signed: 11/17/2021 06:06:49 PM

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: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: 96DATE:
11/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:LaTonya Erebholo - Executive Director/AdministratorTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced for the purpose of conducting a initial inspection regarding complaint (#18-AS-20211109095248). LPA Colvin met with Executive Director/Administrator LaTonya Erebholo. During today's complaint investigation, LPAs observed a warning in an employee's file (S1) regarding an event on 7/24/21 where S1 left residents in the Memory Care building unattended for 15 minutes without additional staff to provide supervision. LPA Colvin contacted staff back at the Regional Office for Community Care Licensing and confirmed that this incident was not reported and that there was no Special Incident Report (SIR) on file from the facility. Deficiency cited.

Due to observations made by LPA Colvin, the facility was cited, and deficiency was noted on LIC 809 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 809D, and appeal rights were provided to Executive Director/Administrator LaTonya Erebholo during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports...including...the following:
(1) A written report shall be submitted...within seven days of...of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident...
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This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one event. LPAs observed a warning notice regarding leaving residents in Memory Care unsupervised on 7/24/21, which was not reported to CCL. This is an immedate personal rights violation.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021
LIC809 (FAS) - (06/04)
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