336426464-5-9-2023-18-AS-EMAN-CRUL9Y-20230515083419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426464
Report Date: 05/09/2023
Date Signed: 05/09/2023 12:19:04 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
11/16/2020 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201116140847

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:	0	CENSUS: 0	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	11:32 AM
MET WITH:	Brian Taube-Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff neglected resident by leaving resident unattended, which resulted in resident sustaining a fall.
Facility staff does not take resident's to their scheduled appointments.
Facility is not following their plan of operation and admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility to deliver findings for the above complaint allegations. LPA met with Executive Director Brian Taube and explained the reason for the visit. During a visit on 3/14/23, LPA discovered that the facility is under new ownership, changed their name, and has mostly new staffing.

The investigation was initiated in 12/28/2020 which consisted of interviews and file review revealed the following:

For allegation, Facility staff neglected resident by leaving resident unattended, which resulted in resident sustaining a fall:

It was alleged that Resident R1 was left unattended for a few minutes and fell out of their wheelchair.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 18-AS-20201116140847

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: 05/09/2023

NARRATIVE

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During interviews with staff, staff did not recall R1 being left unattended in their wheelchair.

During interviews with residents, LPA did not find any residents that knew about R1's fall and did not have issues with staffing leaving the residents unattended.

During interview with R1, R1 attempted to interview R1 on 3/14/23, but they were not at the facility during the visit. On 4/12/23, R1 passed away.

During document review, the facility did not have documents pertaining to R1’s fall.

For allegation, Facility staff does not take residents to their scheduled appointments:

During interviews with staff, staff stated that the residents are provided with transportation to their scheduled appointments. The staff denied not taking residents to their scheduled appointments.

During interviews with residents, the residents did not have any complaints about not being taken to their scheduled appointments.

During document review, LPA found the facility’s admission agreement outlines the transportation for appointments.

For allegation, Facility is not following their plan of operation and admission agreement:

During interviews with staff, the staff denied not following the admissions agreement for transportation.

During interviews with residents, the residents did not have any complaints about the facility not following their admissions agreement for transportation.

During document review, LPA found the facility’s admission agreement outlines the transportation for resident’s appointments.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20201116140847

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: 05/09/2023

NARRATIVE

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Based on the evidence found during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Executive Director Brian Taube, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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