336405887-6-8-2022-18-AS-MVAO-CV2QXX-20230825123416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336405887
Report Date: 06/06/2022
Date Signed: 06/08/2022 08:42:13 AM

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
05/31/2022 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220531150509

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:	DATE:	06/06/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:			TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident suffered falls while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to initiate an investigation into the above allegation. LPA met with Administrator Emely Rodriguez and explained the purpose of the visit. Ms. Rodriguez accompanied LPA on a tour of the facility. LPA conducted interviews with Emely Rodriguez (S1), R1, R2, and retrieved documentation. It was alleged that the facility is not providing care and R1 suffered falls as a result of that neglect. Through interviews conducted and facility documentation, R1 was checked on throughout the night. Facility staff heard resident call for help at approximately 1155PM, and responded. Based on R1's statement of back pain, 911 was called. Based on interview with R1, it was determined that R1 is assisted as needed by staff. R1 denied facility staff neglect R1's needs. Thus, this complaint was deemed to be UNSUBSTANTIATED. A finding of UNSUBSTANTIATED meansthat 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, and a copy of this report, along with a copy of the LIC811 was discussed with and provided to Ms. Rodriguez.

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: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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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