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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336405886
Report Date: 03/22/2023
Date Signed: 03/22/2023 04:16:41 PM


Document Has Been Signed on 03/22/2023 04:16 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:INTEGRATED CARE COMMUNITIES - B2FACILITY NUMBER:
336405886
ADMINISTRATOR:EMELY C. RODRIGUEZFACILITY TYPE:
740
ADDRESS:14315 NASON STREETTELEPHONE:
(951) 601-9170
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:20CENSUS: 15DATE:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Luz Rodriguez, Care ConsultantTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address a potential violation reported during the investigation of complaint #18-AS-20230314155846. The LPA met with Luz Rodriguez, Care Consultant, and informed her of the purpose of the visit.

The LPA received a verbal report on March 22, 2023, of a resident (R1) sustaining injuries as a result of being pushed by a staff member (S1). The LPA conducted staff/resident interviews, reviewed records, and took copies of relevant documentation. According to an Unusual Incident Report (UIR) R1, on March 14, 2023, sustained a fall, was observed to be bleeding, and emergency services was called.

R1 was interviewed; R1 reported they were pushed by an unknown staff member, injured their head, and was later transported to the hospital.

According to Rodriguez, video surveillance captured the alleged incident. The LPA reviewed the recording and observed a resident, appearing to be R1, having an argument with an unidentifiable individual. The recording shows S1 stumbling and eventually falling on their back. The recording did not capture any other individual(s), though a second voice can be heard. Staff reported the second voice heard in the recording is of S1. Staff also reported S1 would have been the only staff on shift at the time of the incident.

If additional information is received indicating a violation occurred, then a follow up visit will be conducted. This report was reviewed with Rodriguez and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (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.

LIC809 (FAS) - (06/04)
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