331881349-4-18-2023-18-AS-RORN-DNZMPP-20251203084725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881349
Report Date: 04/18/2023
Date Signed: 04/18/2023 04:45:54 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
04/11/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230411113844

FACILITY NAME:	MANZANITA VILLAGE AT RANCHO BELAGO		FACILITY NUMBER:	331881349
ADMINISTRATOR:	TAYLOR, KAMESHI		FACILITY TYPE:	740
ADDRESS:	27900 BRODIAEA AVENUE		TELEPHONE:	(951) 379-0100
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	125	CENSUS: 64	DATE:	04/18/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Lucia Gutierrez, Business Office Manager		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff prohibiting resident from having PRN medication at the facility

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs), Stephanie Torres and Cheryl Goodrich, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPAs met with Business Office Manager, Lucia Gutierrez, and informed her of the purpose of the visit.

The LPA conducted staff/resident interviews, reviewed records, and took copies of relevant documentation.

Regarding the allegation, "Staff prohibiting resident from having PRN medication at the facility," it was alleged facility staff required an agency, who was contracted to provide healthcare services to Resident One (R1), to discontinue PRN (Pro Re Nata) medications. Interviews revealed R1 is contracted to receive services from an outside agency. Interviews revealed the facility did request the outside agency of R1 to discontinue unused PRN medications that have remained unused for two months. Executive Director (ED), Kameshi Taylor, was interviewed and confirmed the facility did request outside agencies to no longer store medications not being regularly used by residents in care. Taylor denied requiring outside agencies to remove the medication without

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

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-20230411113844

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: MANZANITA VILLAGE AT RANCHO BELAGO	FACILITY NUMBER: 331881349
	VISIT DATE: 04/18/2023

NARRATIVE

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approval by the resident and/or resident's responsible party. R1's responsible party was interviewed and reported no option was given by the facility to retain the medication. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

This report was reviewed with Gonzalez and a copy was provided.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC9099 (FAS) - (06/04)

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