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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800166
Report Date: 09/03/2025
Date Signed: 09/03/2025 04:00:03 PM

Document Has Been Signed on 09/03/2025 04:00 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:RANCHO BELAGO RESIDENTIAL CAREFACILITY NUMBER:
331800166
ADMINISTRATOR/
DIRECTOR:		KHAN, MUSARRATFACILITY TYPE:
740
ADDRESS:13816 NATHAN PLACETELEPHONE:
(951) 242-8875
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 4DATE:
09/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:LICENSEE,ANSARI SALEEM TIME VISIT/
INSPECTION COMPLETED:
04:08 PM
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On September 03, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and conducted the Annual Inspection. LPA met with the Licensee, Ansari SaLeem, and introduced herself. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for six Adults, but is currently operating at capacity of four Adults (735).

LPA Mixson toured the facility along with the Licensee, Ansari SaLeem and made observations. LPA inspected the facility inside and outside there is clutter or obstructions to the indoor or outdoor passageways currently. Additionally, there are no bodies of water on the premises. The facility is a single-story home located at 13816 Nathan Place Moreno Valley, CA. 92555.

Physical Plant: The facility phone number is (951) 242-8875 and it is operable. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected the facility bathrooms, and the hot water temperature tested within regulations. The bathrooms are clean, and the appliances are operating appropriately at this time. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and additional postings. The cleaning supplies and sharp items are locked and inaccessible to the residents in care currently. There are designated storage space for the residents and staff files, and it is locked and inaccessible to residents.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. There were no documented errors on the centrally stored medication form, and medications appeared to be stored in their original containers. Facility has a medication court which was clean, locked and organized.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents at this time. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. The overall facility is clean; the furniture is in good condition. The facility cooling system and other appliances were operable at present. Licensee, Ansari, informed LPA there were safety lights for night throughout the facility.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Venus Mixson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: RANCHO BELAGO RESIDENTIAL CARE
FACILITY NUMBER: 331800166
VISIT DATE: 09/03/2025
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Records Reviewed Staff & Resident Files: LPA reviewed staff files and reviewed the facility's staff schedule. The staff files reviewed have criminal clearance, updated training, along with current First Aid certification. Resident files reviewed had required paperwork as per Regulations. Residents' files reviewed maintained the following; identification and emergency information, admission agreement, medical assessment, and clients weights. LPA saw the TB test were current. LPA reviewed residents' needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found required infection control measures met the Department requirements.



Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder.

An exit interview was conducted. A copy of this report was given to Licensee, Ansari SaLeem

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Venus Mixson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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