331881349-1-22-2025-18-AS-RORN-DQYMQJ-20260204084847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881349
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:44:15 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
01/02/2025 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20250102161349

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: 102	DATE:	01/22/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Brooke Abrego Huerta, Executive Director		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff are not properly supervising residents who may be a fall risk

INVESTIGATION FINDINGS:

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

A report was received by the Department alleging multiple calls were being made to emergency services (911) for Resident One (R1) relating to falls, where the resident was found in common areas of the building, indicative of the facility staff not meeting the resident's level of care needs. The investigation, which was started on 01/07/2025, involved staff and resident interviews, review of records, and collection of relevant documentation. Three (3) of five (5) resident interviews revealed facility staff are meeting their care needs. Four (4) of five (5) interviews with care staff reported the facility was meeting R1's care needs. Of those interviews, four (4) staff reported there have been at least two (2) and up to seven (7) calls made to 911 in response to an incident or concerning observation involving R1. Medical records were obtained and revealed only four (4) calls were made to emergency services for R1, resulting in the resident being transported to a local hospital.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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-20250102161349

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: 01/22/2025

NARRATIVE

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Of the four (4) calls for service, one (1) call was made relating to a fall the resident sustained. Two (2) of four (4) calls for service resulted in R1 being admitted to the hospital for additional medical treatment.

An AMR (American Medical Response) Patient Care Report, dated 10/21/2024, revealed AMR responded to the facility for R1 who experienced a witnessed ground level mechanical fall. The report revealed the resident presented alert and oriented times two (X2) with no medical complaints. According to the report, facility staff explained how R1 fell forward while walking outside, losing their footing on a curb. The report revealed R1 denied hitting their head, did not lose consciousness, and did not want to go to the hospital. The report revealed facility staff expressed their desire to have R1 transported due to the mechanism of the fall and R1's recent behavior challenges with staff. R1 was later transported to a local hospital.

An Unusual Incident/Injury Report (UIR) from the facility was available for review for the 10/21/2024 incident. The report revealed R1 was exit seeking, exited the memory care building into the secured courtyard, started swinging at staff, and fell onto their knees after tripping over a flower bed. The report revealed R1 complained of pain to their knees after their fall. Staff #1 (S1) was identified to be present during the incident in both the AMR Patient Care Report and the UIR. An interview was attempted with S1; however, no response was received prior to the closure of the investigation. R1 also could not be reached for an interview prior to the closure of the investigation. No additional information was obtained that could either refute or corroborate the validity of the allegation.

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 Executive Director Abrego-Huerta and a copy was provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC9099 (FAS) - (06/04)

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