336426464-11-23-2022-18-AS-EMAN-CLNSW3-20221130131340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426464
Report Date: 11/23/2022
Date Signed: 11/23/2022 01:27:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2020 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200922101928

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: 72	DATE:	11/23/2022
		UNANNOUNCED	TIME BEGAN:	11:23 AM
MET WITH:	Kameshi Taylor		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff threatened resident while in care
Staff is mistreating resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility to investigate and deliver findings to the above allegations. LPA Guerrero identified herself to Administrator, Kameshi Taylor, who was informed of the purpose of the visit. The investigation consisted of direct observations, records review, and interviews with staff and residents. Regarding the above allegations, LPA Guerrero was unable to interview Resident#1 at the facility due to R1 no longer living at the facility.

The first allegation indicates: staff threatened resident while in care. LPA interviewed Resident#1 (R1) who stated she moved out of the facility about a year ago (2021) and had no further comment since she is no longer living at the facility. Resident#2 (R2) Resident#3 (R3) Resident#4 (R4) and Resident#5 (R5) who all denied staff members are threatening residents while in care. Interviews with Staff #1 (S1) Staff #2 (S2) Staff#3 (S3) Staff#4 (S4) and Staff#5 (S5) were made, and they all stated that they have never witness staff threatened residents while in care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

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-20200922101928

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: RENAISSANCE VILLAGE RANCHO BELAGO	FACILITY NUMBER: 336426464
	VISIT DATE: 11/23/2022

NARRATIVE

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The second allegation indicates: staff is mistreating resident while in care. Interview with Resident#2 (R2) Resident#3 (R3) Resident#4 (R4) and Resident#5 (R5) stated staff have never mistreated them while in care. S1, S2, S3, S4, S5, stated they have never witness staff mistreat residents while in care.

Based on evidence obtained during today’s visit, LPA Guerrero has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to the Administrator Kameshi Taylor at the conclusion of the visit.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

LIC9099 (FAS) - (06/04)

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