336405885-3-22-2023-18-AS-DMUN-CQESQD-20230330140431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336405885
Report Date: 03/22/2023
Date Signed: 03/22/2023 02:57:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/14/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230314155846

FACILITY NAME:	INTEGRATED CARE COMMUNITIES - B1		FACILITY NUMBER:	336405885
ADMINISTRATOR:	EMELY C. RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	14295 NASON STREET		TELEPHONE:	(951) 601-9150
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	20	CENSUS: 14	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Luz Rodrigues, Care Consultant		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff pushed resident resulting in injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Luz Rodriguez, Care Consultant, and informed her of the purpose of the visit.

The LPA conducted staff/resident interviews, reviewed records and took copies of relevant documentation. A report was received alleging an unknown female resident was pushed by an unknown staff member on or around March 14, 2023. Hospital records and an interview revealed the only female resident who was sent to the hospital around March 2023 was Resident One (R1). The hospital records show R1 sustained injuries, including an acute nonintractable headache and hematoma of scalp in relation to an unwitnessed fall. An Unusual Incident Report (UIR) was obtained and shows R1 did sustain a fall on March 06, 2023 at approximately 8:10 PM. The report indicates R1 was discovered laying on the floor by bedside by Staff One (S1). The report indicates R1 was observed to have blood on their forehead. R1 was interviewed and denied having a fall and denied anyone pushing them. S1 was interviewed and denied pushing R1. A Timecard Report

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230314155846

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: INTEGRATED CARE COMMUNITIES - B1	FACILITY NUMBER: 336405885
	VISIT DATE: 03/22/2023

NARRATIVE

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and staff interviews revealed S1 was the only staff on shift at the time of the fall. Resident Two (R2) who reported being present during the fall was interviewed; R2 denied having knowledge of anyone pushing R1. R2 also denied anyone else was present in the bedroom during the fall. Therefore, based on information obtained, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

This report was reviewed with Rodriguez and a copy was provided.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

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