198603646-5-20-2025-28-AS-THEA-DGUTWF-20250520150529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603646
Report Date: 05/20/2025
Date Signed: 05/20/2025 03:05:47 PM

Document Has Been Signed on 05/20/2025 03:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	INTEGRATED LIFE LLC		FACILITY NUMBER:	198603646
ADMINISTRATOR/ DIRECTOR:	DE LEON, CORINA		FACILITY TYPE:	775
ADDRESS:	10329 ARTESIA BOULEVARD		TELEPHONE:	(562) 202-9942
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 30		CENSUS: 20	DATE:	05/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Leslie Ramirez – Program Manager		TIME VISIT/ INSPECTION COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced visit for an Annual Inspection. LPA met with Leslie Ramirez – Program Manager, and the purpose for the visit was explained. The facility is licensed to serve 30 Adults ages 18, which (10) may be non-ambulatory. This is a single- story facility located in Bellflower, Ca. A tour of the facility includes: Lobby with Client Lockers, Storage Room, Locked Management Office (where files and PRN medications are kept), Art Room, Computer Lab, Fitness Room, Leisure Room (and Kitchen), Conference Room, Program Coordinator Office, Staff Break Room, Staff Office, Relaxation Room, Cleaning Supplies/Laundry Room, Additional Storage Room and Mens/Womens restroom with stalls. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility maintain the required Infection Control Plan. Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and are fully charged. No bodies of water were observed at the facility. The hot water temperature was tested in the kitchen and measured within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, poisons and hazardous items are stored in a secured/locked storage closet and inaccessible to clients. Clients have a water station available in the kitchen and clients are provided water bottles. The facility appears to be clean safe and sanitary. Operational Requirements: The facility has the appropriate fire clearance. Staff are knowledgeable on their reporting requirements. (Continued on 809-C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: INTEGRATED LIFE LLC	FACILITY NUMBER: 198603646
	VISIT DATE: 05/20/2025

NARRATIVE

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Staffing: There appears to be sufficient staffing at all times in the facility. There are at least 2 staff members on duty any time there are clients in the facility.
Personnel Records-Training: Staff files were readily available during visit. LPA reviewed 5 staff files, each file reviewed have criminal record clearance, current First Aid/CPR/AED/CPI and sufficient on-going training. Program Director the education, proper training and experience to meet the requirements. LPA observed Staff #1 and Staff #2 with expired First-Aid certificates, citation issued and details can be found on the LIC809-D page.
Client Records-Incident Reports: Client files are kept in a secure location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Consent Forms, and Appraisal Needs & Services Plan. LPA reviewed 5 client records no issues.
Client Rights-Information: Client Rights Poster is posted within the facility.
Food Service: Pesticides and other similar toxic substances are not stored with the food. Clients bring their lunches and staff will provide snack to clients.
Health Related Services: Clients with incontinence at the facility are kept clean and dry, and the facility is free of any odors. Only one client today had PRN sent with them to facility and medication is properly labeled and stored in a secure/locked area and are inaccessible to clients.
Incidental Medical & Dental: Staff have proper training documented within the personnel files and files are reviewed annually.
Disaster Preparedness: There is an Emergency Disaster Plan with contact numbers and relocation sites.
Emergency Intervention: Clients at this facility have not needed the use of restraints or the use de-escalation techniques, however, staff do maintain a valid CPI certificate.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on the LIC809-D page.

Exit interview was held and a copy of the report and appeal rights were provided to Leslie Ramirez.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2025 03:05 PM - It Cannot Be Edited

Created By: Tena Herrera On 05/20/2025 at 02:48 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: INTEGRATED LIFE LLC	FACILITY NUMBER: 198603646
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 2 out of 5 staff had expired First-Aid certificates on file, Staff #1 is scheduled to renew at end of month (cert expired 12/2024) and Staff #2's last certificate on file expired 6/2021, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2025
	Plan of Correction
1 2 3 4	Administrator/ Licensee to have staff with expired First-Aid certificates complete training and email a copy of renewed First-Aid Certificates with valid expiration dates to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC809 (FAS) - (06/04)

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