331881349-8-19-2025-18-AS-APEZ-DMUP8H-20251027110535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881349
Report Date: 08/19/2025
Date Signed: 08/19/2025 03:26:35 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
10/16/2024 and conducted by Evaluator Valerie Flores

COMPLAINT CONTROL NUMBER: 18-AS-20241016142418

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: 125	DATE:	08/19/2025
		UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Assistant Director, Anna Martinez		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff was negligent in resident's death

INVESTIGATION FINDINGS:

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On 8/19/2025, Licensing Program Analyst (LPA) Valerie Flores arrived at the facility unannounced for the purpose of delivering findings of the listed allegations. LPA Flores met with Assistant Director, Anna Martinez, and a tour of the facility was conducted.
On 4/12/2023, Community Care Licensing (CCL) received a complaint alleging facility staff was negligent in resident's death. Information obtained through interviews revealed staff attempted to assist Resident #1 (R1) with showering, while doing so R1 became agitated, R1’s agitation is related to R1s cognitive impairment which became noticeable after a change in R1s medication. This is consistent with Needs/Service Plan-File Review. According to information obtained R1 did not want to shower. Staff would assist R1’s showering needs during the evening for R1 to be presentable at church services, at the request of R1’s Responsible party. R1’s shower schedule would vary depending on R1’s mood. R1’s agitation increased, and staff attempted to mitigate the situation by using a “change of face” technique.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

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-20241016142418

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: 08/19/2025

NARRATIVE

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The change of face technique is a non-confrontational behavior intervention used when a resident becomes agitated during an interaction with a particular staff. The approach involves substituting the current staff with a different staff member, often leading to a reset in the residents emotional state.
Through interviews, it was alleged that while showering R1, R1 took a step backwards, lost their balance, fell, and struck their head on the wall. The facility staff attempted to catch R1 prior to the fall but their attempt was unsuccessful. The facility’s protocol does not allow staff to move the residents after an injury as it may harm the residents. The ambulance was immediately called, however, a valid signed, Do Not Resuscitate (DNR) was located in R1’s file. Through observations, the facility’s bathrooms complied with Title 22, regulation 87303, as showers were equipped with non-skid mats and grab bars. In addition, information obtained through interviews revealed that the facility’s protocol after any client falls, the service plan will be updated based on any specific need. This is to prevent any further falls and address safety measures. Residents will also participate in a re-evaluation provided by a medical professional after so many fall incidents. No reassessment was completed due to R1 passing.
Furthermore, the facility complied with all protocols pertaining to R1’s needs and service plan, such as conducting checks on R1 and assisting R1 with their medications. Staffs training records were current, Staff implemented de-escalation techniques pertaining to R1’s agitated state at the time of the incident. According to the autopsy received by the Coroner’s Office, the reported cause of death was accidental and due to blunt force trauma.
Based on observations, interviews and records reviewed, the allegation of staff was negligent in resident's death is unsubstantiated. A finding that is unsubstantiated means although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where a copy of this report was reviewed and provided to Assistant Director, Anna Martinez.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

LIC9099 (FAS) - (06/04)

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