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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881349
Report Date: 10/28/2025
Date Signed: 10/28/2025 11:51:27 AM

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
04/11/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 18-AS-20230411113844
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:
10/28/2025
UNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Anna Martinez/Assistant Executive DirectorTIME COMPLETED:
11:51 AM
ALLEGATION(S):
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Resident billing statement does not clearly state charges.
Staff are not providing services agreed upon in the resident's Admission Agreement.
INVESTIGATION FINDINGS:
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On 10/28/2025, 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 included 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), the Admission Agreement for Resident #1 (R1), the billing statement for R1 (dated 05/28/2024), the Medication Administration Record (MAR) (dated October 2025) for residents #2-6, and the Physician Report for residents #2-6. LPA interviewed the Assistant Executive Director (AED), Med Tech (MT), the Dining Services Manager (DSM), two staff members (S1-S2), and five residents (R2-R6). The facility's weekly menu and the optional menu (dated October 26 through November 1, 2025) were also reviewed. A copy of the beautician schedule and services was obtained (2024).

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
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-20230411113844
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: 10/28/2025
NARRATIVE
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Allegation #2: The Resident's billing statement does not clearly state charges.

The complaint alleged that the financial statements provided to the residents' responsible party were inaccurate. On October 27, 2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the Assistant Executive Director (AED). The AED denied the allegations and explained that when the administration increased a resident's care level, the facility was required to conduct a new pre-appraisal to assess the resident's care needs. The AED also noted that the issue with the R1 billing statement was related to the previous administration and that the facility had corrected the problem. Additionally, the AED pointed out that the facility's admission agreement stated that rates would increase annually and that the responsible party would be notified in writing of any increase two months prior.

During the same time period, LPA interviewed four staff members (S1-S4), all of whom denied the allegations. Later on, on October 27, 2025, from approximately 1:30 PM to 2:30 PM, LPA interviewed five residents (R2-R6). Three out of the five residents denied the allegations, stating that their representative would receive a letter regarding the matter.

On October 23, 2025, LPA interviewed R1's responsible party, who confirmed that, following the new administration's takeover, they had refunded all charges. LPA's review of the R1 billing statement, dated January 31, 2023, indicated that the responsible party received a credit for the discrepancy. Unfortunately, LPA was unable to interview R1, as R1 passed away in December 2023.

Report Continued on LIC9099C

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

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20230411113844
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: 10/28/2025
NARRATIVE
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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.

Allegation #3: Staff are not providing services as agreed upon in the resident’s admission agreement.

The complaint alleged that the resident relied on the services of a beauty shop on the premises, which was listed as a service in the admission agreement. The new administration terminated the beauty shop's services. On 10/27/2025, between approximately 10:00 AM and 12:30 PM, the LPA Richard interviewed the AED, who denied the allegations and stated that the facility has a beautician who comes every Wednesday to provide beauty services to residents. Furthermore, the LPA interviewed four staff members (S1-S4), who denied the allegation and said that the facility has a beautician who visits to assist residents with haircuts, nails, Shampoo, and other needs. On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents (R2-R6) denied the allegations and stated that a beautician visits them and helps them with their beauty needs. They also felt it was a good idea for the beauticians to come to their rooms to meet their needs. On 10/27/2025, the LPA reviewed the beautician's schedule, including services provided to residents upon request, and documented the dates and times of these services since 2024. Unfortunately, LPA was unable to interview R1, as R1 passed away in December 2023.

Report Continued on LIC9099C

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

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20230411113844
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: 10/28/2025
NARRATIVE
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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: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4