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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336405884
Report Date: 07/08/2024
Date Signed: 07/08/2024 03:01:19 PM


Document Has Been Signed on 07/08/2024 03:01 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:EMELY C. RODRIGUEZFACILITY TYPE:
740
ADDRESS:14265 NASON STREETTELEPHONE:
(951) 601-9100
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:22CENSUS: 19DATE:
07/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Amanda Redell, Facility ManagerTIME COMPLETED:
03:10 PM
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Licensing Program Analysts (LPAs), Stephanie Martinez and Seo Jeon, conducted an unannounced visit to the home to follow up on an Unusual Incident/Injury Report (UIR) received from the facility on 06/24/2024. The LPA met with Amanda Redell, Facility Manager, and informed her of the purpose for the visit. Administrator, Emily Rodriguez, was notified of the visit via telephone.

A UIR was received by the Department from the facility reporting an alleged incident of abuse between a staff member and resident in care. According to the report, Resident One (R1) reported that on 06/19/2024 Staff One (S1) placed their hands around their neck and threw R1 to the ground. It was also reported R1 called emergency services (911); however, S1 would not allow the personnel inside the home.

During the visit the LPA conducted staff and resident interviews, reviewed records, and obtained copies of relevant documentation. No immediate health and safety concerns were observed at time of visit. No one by the name of S1 was listed on the facility's staff schedule. Additional time is required, in order to obtain further information, prior to the conclusion of this investigation.

This report was reviewed with Facility Manager Redell and a copy of the report was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2024
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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