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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881349
Report Date: 10/27/2025
Date Signed: 10/27/2025 03:42:57 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
03/06/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 18-AS-20230306151448
FACILITY NAME:MANZANITA VILLAGE AT RANCHO BELAGOFACILITY NUMBER:
331881349
ADMINISTRATOR:TAYLOR, KAMESHIFACILITY TYPE:
740
ADDRESS:27900 BRODIAEA AVENUETELEPHONE:
(951) 379-0100
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:125CENSUS: 124DATE:
10/27/2025
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Anna Marinez/Assistant Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility has insufficient staffing to meet residents' needs.
Staff failed to provide adequate food service.
INVESTIGATION FINDINGS:
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On 10/27/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit to gather information and deliver findings regarding the above allegations. LPA met with Anna Martinez, Assistant Executive Director, and the purpose of the visit was explained. LPA was granted entry to the facility.

The Investigation consisted of the following: On 10/27/2025, LPA Richard reviewed and obtained the Residents' Roster (dated 07/11/2025), the Staff Roster (dated 06/25/2025), Medication Administration Record (MAR) (dated October 2025) for residents #1-5, and the Physician Report for Residents #1-5. LPA interviewed the Assistant Executive Director (AED), Med Tech (MT), the Dining Services Manager (DSM), two staff members (S1-S2), and five residents (R1-R5). The facility's weekly menu and the optional menu (dated October 26th through November 1st, 2025).

Report Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20230306151448
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: 10/27/2025
NARRATIVE
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Allegation #1: Facility has insufficient staff to meet residents’ needs.

The complaint alleged that residents are paying a significant amount of money, but their needs are not being met. On 10/27/2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the AED, who denied the allegations and stated that we have enough staff to care for and meet the residents' needs. The AED also noted that the facility has staff on call in case of an emergency. LPA interviewed the (MT), who disagreed and said that the facility has more than enough staff to meet the residents' needs. At the same time, LPA interviewed (DSM), who denied the allegation and stated that we offer various dining services for breakfast, lunch, and dinner to serve residents. LPA also interviewed two staff members (S1 and S2), who denied the allegation and stated that the facility has on-call staff who can help if they are short-staffed. On 10/27/2025, from approximately 1:30 PM to 2:30 PM, LPA interviewed five residents (R1-R5). All five denied the allegation and said the facility served their food on time and met their needs. The caregivers are excellent at caring for them. During the same period, LPA's review of the facility personnel roster showed four on-call caregivers and two on-call Med Techs.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated.

Report Continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20230306151448
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: 10/27/2025
NARRATIVE
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Allegation #2: Staff failed to provide adequate food service.

The complaint alleged that the facility doesn’t serve snacks to the residents in memory care. On 10/27/2025, between approximately 10:00 AM and 12:30 PM, LPA Richard interviewed the AED, who denied the allegations and stated that the facility serves three meals a day and provides snacks between breakfast, lunch, and dinner. At the same time, the LPA also interviewed the (MT), who denied the allegation. Additionally, the LPA interviewed with the (DSM), who denied the allegation and explained that they provide a great weekly menu and an options menu in case a resident does not like what is on the regular menu that day. They also offer snacks between meals for all residents.

Furthermore, the LPA interviewed two staff members (S1-S2), who denied the allegation and stated that the residents have many food options. On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents denied the allegation and stated that the facility provides them with adequate food and snacks between meals. They also said that if they don’t like what food they are served, they can order something else.

Report continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20230306151448
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: 10/27/2025
NARRATIVE
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On 10/27/2025, LPA reviewed the facility's weekly menu, and the optional menu (dated Oct 26th - Nov 1st, 2025) showed a variety of food choices for the residents. LPA Richard observed the facility serving lunch at 12:00 pm; the residents had a large portion of food with side dishes, fruit, salad, dessert, and different types of beverages.

Based on the LPA observations, interviews, and record reviews, the Preponderance of evidence standard has not been met. Although the allegation may have happened 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.

No deficiency cited.

An exit interview was conducted. A copy of the report was provided to the Assistant Executive Director Anna Martinez.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4