Rancho Belago Residential Care

Type of visit: Required - 1 Year

On September 03, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and conducted the Annual Inspection. LPA met with the Licensee, Ansari SaLeem, and introduced herself. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for six Adults, but is currently operating at capacity of four Adults (735). LPA Mixson toured the facility along with the Licensee, Ansari SaLeem and made observations. LPA inspected the facility inside and outside there is clutter or obstructions to the indoor or outdoor passageways currently. Additionally, there are no bodies of water on the premises. The facility is a single-story home located at 13816 Nathan Place Moreno Valley, CA. 92555. Physical Plant: The facility phone number is (951) 242-8875 and it is operable. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected the facility bathrooms, and the hot water temperature tested within regulations. The bathrooms are clean, and the appliances are operating appropriately at this time. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and additional postings. The cleaning supplies and sharp items are locked and inaccessible to the residents in care currently. There are designated storage space for the residents and staff files, and it is locked and inaccessible to residents. Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. There were no documented errors on the centrally stored medication form, and medications appeared to be stored in their original containers. Facility has a medication court which was clean, locked and organized. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents at this time. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. The overall facility is clean; the furniture is in good condition. The facility cooling system and other appliances were operable at present. Licensee, Ansari, informed LPA there were safety lights for night throughout the facility. Records Reviewed Staff & Resident Files: LPA reviewed staff files and reviewed the facility's staff schedule. The staff files reviewed have criminal clearance, updated training, along with current First Aid certification. Resident files reviewed had required paperwork as per Regulations. Residents' files reviewed maintained the following; identification and emergency information, admission agreement, medical assessment, and clients weights. LPA saw the TB test were current. LPA reviewed residents' needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found required infection control measures met the Department requirements. Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate. Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. An exit interview was conducted. A copy of this report was given to Licensee, Ansari SaLeemthe state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Yolanda Delgado and Debbie Palacios arrived unannounced to conduct an annual inspection. Upon arrival LPA's was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. Resident record review began- Four (4) records were reviewed. LPA's reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPA's toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 112.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA's verified there is a telephone working at this location. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. (Continued on next page) (Continued on next page) LPA's began review of employee records- Two (2) records were reviewed. LPA's reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 04/29/2024. The facility is conducting emergency disaster drills; not quarterly. The last disaster drill was conducted on 07/28/2024. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there three (3) deficiencies is being cited per Title 22, Division 6 of The California Code of Regulations. This report, 809D and Appeal Rights was reviewed with and a copy provided to the facility representative at the time of the exit interview.the state’s words, verbatim · CDSS document, Sep 9, 2024