336405885-11-27-2024-18-AS-AZEO-DBET2X-20241127132128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336405885
Report Date: 11/27/2024
Date Signed: 11/27/2024 01:21:39 PM

Document Has Been Signed on 11/27/2024 01:21 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 - B1		FACILITY NUMBER:	336405885
ADMINISTRATOR/ DIRECTOR:	EMELY C. RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	14295 NASON STREET		TELEPHONE:	(951) 601-9150
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 20	TOTAL ENROLLED CHILDREN: 0	CENSUS: 16	DATE:	11/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:20 AM
MET WITH:	Emely Rodroguez		TIME VISIT/ INSPECTION COMPLETED:	01:35 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) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by the Administrator Emely Rodriguez notified her of the purpose for the visit and was allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a single story building with 10 residents bedrooms, and 11 bathrooms. There is no gated pool and there are no firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in a kitchen cabinet and inaccessible to residents. The smoke detector and carbon monoxide detector were operational. LPA observed fire extinguishers to be in compliance with the department requirements and with an expiration date of 07/15/2025. LPA observed the hot water temperature to meet requirements at 107.1°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Continued on LIC809-C.....

Rikesha Stamps	TELEPHONE: (951) 212-0616
Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
	DATE: 11/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

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 - B1	FACILITY NUMBER: 336405885
	VISIT DATE: 11/27/2024

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
26
27
28
29
30
31
32

Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of June 10th, 2026 and a CPR certification with the expiration date of 06-25-26

Record Review and Resident/Staff Files: LPA reviewed files for Four(4) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Four (4) residents' files were reviewed and contained all required documentation. LPA observed resident files, to be stored in a locked cabinet in the office. The first aid kit was stored in a cabinet in the office.

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the medication room. LPA reviewed medications for six(6) residents, and noticed medications that were not punched out but marked as given to the resident. A citation will be issued

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 11-06-2024, which met department requirements. All facility exits were clear of obstructions.

An exit interview was conducted, during which this report was reviewed, and a copy was provided to Emely Rodriguez along with the appeal rights

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/27/2024 01:21 PM - It Cannot Be Edited

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 - B1	FACILITY NUMBER: 336405885
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 6 residents missed at least one AM medication, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2024
	Plan of Correction
1 2 3 4	Licensee will conduct staff training on proper medication administration and will send proof of training 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.

Rikesha Stamps	TELEPHONE: (951) 212-0616
Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
	DATE: 11/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3