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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881349
Report Date: 04/05/2024
Date Signed: 04/05/2024 05:57:37 PM

Document Has Been Signed on 04/05/2024 05:57 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MANZANITA VILLAGE AT RANCHO BELAGOFACILITY NUMBER:
331881349
ADMINISTRATOR/
DIRECTOR:		TAYLOR, KAMESHIFACILITY TYPE:
740
ADDRESS:27900 BRODIAEA AVENUETELEPHONE:
(951) 379-0100
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 125CENSUS: 76DATE:
04/05/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Brooke Abrego Huerta, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to continue the required annual inspection which was started on 03/08/2024. The LPA was allowed entrance into the facility and met with Administrator, Brooke Abrego Huerta. Abrego Huerta was notified of the purpose for the visit. The facility currently has an approved Hospice Waiver for twenty (20) residents. The inspection included the following:

Physical Plant: A tour of the facility's interior and exterior areas was completed; resident bedrooms were clean, had the required furniture and had sufficient lighting. There are no bodies of water located on the property. According to Administrator, Abrego Huerta, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet and shower used by residents. Bathroom faucets, showers, and toilets were observed to be in working order. Resident showers have non-skid material present. The LPA inspected the fire alarm panel and observed the system to show "normal". According to facility staff, the carbon monoxide and smoke detectors are combined on one device. The LPA observed a sprinkler system to be available in the bedrooms where bedridden residents were residing. The facility was observed to be clean and free of odors.

Food Service: There is a minimum of 2 days of perishable foods and 1 week's supply of non-perishable foods available. The facility kitchen was toured and observed to be clean. Supplies were observed to be available. No presence of insects or rodents was observed in the kitchen areas.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care training, Restricted Health Conditions training, and Hospice training was observed to be available and complete. Staff training records revealed the facility has also provided staff with additional training, such as personal rights training. The LPA was informed by Administrator Abrego Huerta that there are currently thirteen (13) residents in care who are receiving hospice
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/05/2024
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services. Hospice Care Plans were observed on file at the facility. There is a disaster and mass casualty plan in place. Proof of emergency drills were observed on file. All services requiring specialized skill are being performed by residents or personnel qualified as appropriately skilled professionals. The facility was observed to not be operating beyond the conditions specified on the license.

Medication Review: The LPA reviewed resident medications. Medications were observed to have the required prescriptions on file. The facility's medication room was inspected and found to be clean and inaccessible to unauthorized individuals.

An exit interview was conducted with Administrator Abrego Huerta; this report was reviewed, and a copy was provided. No citations were issued during this visit.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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