336405887-3-16-2023-18-AS-JESL-CQH3U5-20230401183258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336405887
Report Date: 03/16/2023
Date Signed: 03/16/2023 02:47:16 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
07/25/2022 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220725164057

FACILITY NAME:	INTEGRATED CARE COMMUNITIES - A2		FACILITY NUMBER:	336405887
ADMINISTRATOR:	EMELY C. RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	14345 NASON STREET		TELEPHONE:	(951) 601-9190
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	24	CENSUS: 15	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Amber Croft, LVN		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Staff neglected resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to deliver the findings of the above allegation.

LPA met with LVN Amber Croft and toured the facility. During the investigation, the Department conducted interviews with staff and obtained copies of facility records.

An allegation was received stating Staff neglected resident. Resident 1, (R1) was admitted to the facility on July 19, 2019 and was accepted to the facility receiving hospice services. Facility staff became aware of a Stage 2 pressure injury to R1’s coccyx area on March 15, 2022. Facility reported the wound to hospice on the same day.

Continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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-20220725164057

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 - A2	FACILITY NUMBER: 336405887
	VISIT DATE: 03/16/2023

NARRATIVE

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A care plan was developed to care for the wound and treatment to be followed by the hospice nurse and facility staff. Instructions were for staff to turn R1 every 2 hours when hospice nurse was not present. As R1’s wound began to develop to a stage 3 on July 6, 2022, hospice increased treatment for wound care accordingly. On July 18, 2022, Hospice documentation noted that R1’s wound began to heal slightly; however, R1 passed away soon after. Therefore, LPA discovered that there was not enough evidence to corroborate that staff was neglectful in caring for R1 and was unable to dismiss the allegation. As a result, this allegation was deemed to be Unsubstantiated.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where a copy of this report was discussed with and provided along with a copy of the LIC811 (confidential names list).

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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