331881349-8-17-2023-18-AS-RSTS-DL24ZZ-20250829193332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881349
Report Date: 08/17/2023
Date Signed: 08/17/2023 04:27:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
08/15/2023 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230815150547

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: 65	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Brooke Abrego-Huerta, Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff refused to accept resident back into care following a hospitalization
Staff failed to ensure communication from resident's representative was answered promptly

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to investigate the above allegations. The LPA met with Brooke Abrego-Huerta, Executive Director (ED), and informed her of the purpose for her visit.

The investigation included staff interviews, records review, and records collection.

An allegation was received by the Department alleging facility staff were not permitting Resident One (R1) to return to the facility following a planned hospitalization on August 15, 2023. The LPA spoke with Brooke, ED, who reported R1's return to the facility was not denied. Brook reported the facility recommended R1 be transferred to a skilled nursing facility in order for the resident to heal appropriately following their hospitalization. Staff interviews reported a call was received on August 14, 2023 from a representative of the medical center where R1 was hospitalized. It was reported the representative inquired if R1 would be returning to the facility after the hospitalization or if R1 would be transferred to another location. It was reported the

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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-20230815150547

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MANZANITA VILLAGE AT RANCHO BELAGO	FACILITY NUMBER: 331881349
	VISIT DATE: 08/17/2023

NARRATIVE

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representative was notified the ED recommended R1 be transferred to a skilled nursing facility for appropriate care. Staff interview also reported the representative did not disclose the needed care R1 would require after the hospitalization. The LPA attempted to reach the representative, however, attempts were unsuccessful. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

It was also alleged the facility did not ensure communication with R1's representative was answered promptly when the Executive Director (ED) failed to notify the responsible party that R1 would not be permitted to return to the facility after their hospitalization. Interview reported R1's authorized representative was not notified of the decision to refer R1 to a skilled nursing facility, rather than to accept the resident back into care. Brooke, the ED, was interviewed and reported being notified on August 12, 2023 of R1's hospitalization on August 15, 2023. The ED reported notifying R1's representative of options for R1's care following hospitalization, including transfer to a skilled nursing facility. She also reported R1's representative did not notify the facility of the care the resident would require after the hospitalization. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

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

An exit interview was conducted; this report was reviewed with the ED and a copy was provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

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