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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426464
Report Date: 04/25/2022
Date Signed: 04/25/2022 05:47:24 PM


Document Has Been Signed on 04/25/2022 05:47 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:
336426464
ADMINISTRATOR:EREBHOLO, LATONYAFACILITY TYPE:
740
ADDRESS:27900 BRODIAEA AVE.TELEPHONE:
(800) 870-8066
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:125CENSUS: 78DATE:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Latonya Erebholo - Executive DirectorTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on an SOC341 (Elderly/Dependent Adult Abuse Report) regarding a potential inappropriate relationship between a staff member (S1) and a resident (R1). LPA Colvin met with Executive Director Latonya Erebholo and informed her of the purpose of today's inspection.

LPA Colvin reviewed resident and staff files and interviewed Executive Director Latonya and R1. During LPA Colvin's inspection, LPA Colvin learned that S1 no longer works at the facility, and was terminated for reasons unrelated to these concerns. R1 denied claims of having any type of relationship with S1 other than that of care provider and resident. LPA Colvin will conduct any necessary follow up regarding the reported concerns.

An exit interview was conducted with Executive Director Latonya Erebholo and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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