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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336405887
Report Date: 07/08/2021
Date Signed: 07/08/2021 01:19:53 PM

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 - A2FACILITY NUMBER:
336405887
ADMINISTRATOR:EMELY C. RODRIGUEZFACILITY TYPE:
740
ADDRESS:14345 NASON STREETTELEPHONE:
(951) 601-9190
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:24CENSUS: 15DATE:
07/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Emily RodriguezTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced case management visit in response to receiving a death of a Resident 1 (R1). LPA met with Administrator Emily Rodriguez.

During this visit LPA interviewed staff, reviewed and obtained copies of documentation from R1's record and toured the facility, including R1's bedroom. There are no concerns regarding the health and safety of the residents in the home during this visit.

This report was reviewed with and a copy was provided to the administrator.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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