336426464-11-17-2021-18-AS-JESL-CKQNJQ-20221031103043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426464
Report Date: 11/17/2021
Date Signed: 11/17/2021 06:06:07 PM

Substantiated

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
11/09/2021 and conducted by Evaluator Crystal Colvin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211109095248

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:	125	CENSUS: 96	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	LaTonya Erebholo - Executive Director/Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff failed to meet residents' needs

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPAs identified themselves and discussed the purpose of the visit and the elements of the allegation(s) with Executive Director/Administrator LaTonya Erebholo. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff failed to meet residents' needs": During today's inspection, LPAs Colvin and Mixon toured the facility, reviewed staff files, reviewed facility call logs, and conducted interviews. LPAs were able to confirm through multiple interviews that on at least one occasion in the last month, residents who need staff assistance to and from the dining room were left in the dining room after dinner for an extended period of time. Accoding to interviews, residents have had to look for solutions to avoid being left in the dining room, such as pressing their pendants early (right after eating or even during), or trying to avoid calling caregivers during busy times. LPAs additionally reviewed the call pendant logs for all residents for the last 7 days as well as 30 day records for select residents who need more staff assistance.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211109095248

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: 11/17/2021

NARRATIVE

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Review of these records showed calls for assistance which took 30 minutes or longer for staff to respond to and conclude. A number of these calls were coded as "talk" or "other", which did not provide additional explanation for why the response time took so long (such as aiding someone with toileting - coded as "toileting" could take a long amount of time). Therefore, based on interviews and record review, the allegation "Staff failed to meet residents' needs" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiency was noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Executive Director/Administrator LaTonya Erebholo during the exit interview.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 18-AS-20211109095248

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type B 12/01/2021 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents...: (a) In addition to the rights listed in Section 87468.1...residents...shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...This was not met by:	1 2 3 4 5 6 7	Licensee agrees to reassess staffing levels versus number of residents and level of care required by each resident and evaluate whether or not additional staffing is needed. Licensee to provide LPA Colvin with result of evaluation and plan by Plan of Correction date of 12/1/21.
	8 9 10 11 12 13 14	Based on interviews, the Licensee did not comply with the above regulation with multiple residents. LPAs learned through investigation that on at least one occasion in November 2021, residents were left unattended in the dining room for extended period. This was a potetnial personal rights violation of residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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