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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336405884
Report Date: 12/03/2024
Date Signed: 12/03/2024 06:45:15 PM

Document Has Been Signed on 12/03/2024 06:45 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:INTEGRATED CARE COMMUNITIES - A1FACILITY NUMBER:
336405884
ADMINISTRATOR/
DIRECTOR:		EMELY C. RODRIGUEZFACILITY TYPE:
740
ADDRESS:14265 NASON STREETTELEPHONE:
(951) 601-9100
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 22CENSUS: 19DATE:
12/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Emely Rodriguez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to continue the annual inspection that was started on 11/22/2024. The LPA met with Administrator, Emely Rodriguez, and informed her of the purpose for the visit.

Physical Plant: The facility consists of Twelve (12) resident bedrooms, thirteen (13) bathrooms, one (1) laundry room, a kitchen and dinning area, a living room area, a medication room and office, a staff work station and a yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Rodriguez, no weapons are stored at the facility. The facility is being maintained at a comfortable temperature. All indoor passageways were kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet and shower used by residents. Resident showers have non-skid mats present. The hot water temperature was tested and observed to be within regulatory requirements. One carbon monoxide device was tested by staff and was observed to be in operating condition. The facility's smoke alarm panel was observed to show the system was in normal operation. The facility was kept clean, organized and free of any odors. The LPA observed a chain and lock on the only emergency exit in the back yard area of the facility. An interview with the local fire department revealed the chain and lock should not have been placed on the exit gate. A citation and civil penalty will be issued.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care and medication training was observed on file. No postural support training or restricted health training was observed on file for Staff One (S1) or Two (S2). Insufficient hours for hospice training were observed on file for S1 and S2. A citation will be issued. Resident files had admission agreements, medical assessments, appraisal/needs and services plans, and other required records on file. The facility was not operating beyond the conditions specified on the license. The facility
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: INTEGRATED CARE COMMUNITIES - A1
FACILITY NUMBER: 336405884
VISIT DATE: 12/03/2024
NARRATIVE
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currently has an approved Hospice Waiver for ten (10) residents and there are currently five (5) residents in care receiving hospice services. There is a disaster and mass casualty plan in place. Proof of emergency drills was observed on file. According to Administrator Rodriguez, the corporation is currently active. The LPA observed current liability insurance on file.

Medication Review: The LPA inspected resident medications. Medications were observed to be well organize and inaccessible to unauthorized individuals. Centrally stored medication destruction records were observed on file.

Administrator Rodrgiuez reported an updated admission agreement was established by the licensee and she agreed to provide the LPA with a copy for department review. She also agreed to provide the LPA with a copy of the current liability insurance, staff schedule, and resident roster.

An exit interview was conducted with Administrator Rodriguez, in which this report was reviewed and a copy was provided, along with supportive documents. Administrator reported she had no questions regarding the report.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
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Document Has Been Signed on 12/03/2024 06:45 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 12/03/2024 at 05:43 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: INTEGRATED CARE COMMUNITIES - A1
FACILITY NUMBER: 336405884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 emergency exits being locked and unavailable as a fire exit. The LPA observed a chain & lock on the only emergency exit in the back yard area of the facility. An interview with the local fire department revealed the chain and lock should not have been placed on the exit gate. This poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Staff immediately removed the lock from the gate at the time of the visit. Administrator Rodriguez reported an in-service training will be completed to ensure all staff are aware the emergency exit is not to be blocked off.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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Document Has Been Signed on 12/03/2024 06:45 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 12/03/2024 at 05:52 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: INTEGRATED CARE COMMUNITIES - A1
FACILITY NUMBER: 336405884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff members who did not have the above required training. No postural support training or restricted health training was observed on file for S1 or S2. Insufficient hours for hospice training were observed on file for S1 and S2. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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Administrator Rodriguez reported the training will be completed for S1 and S2 and proof will be submitted to the Department by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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