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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402567
Report Date: 07/18/2022
Date Signed: 07/18/2022 02:15:11 PM

Document Has Been Signed on 07/18/2022 02:15 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
, CA 92507
FACILITY NAME:INLAND ADULT DEVELOPMENTAL CENTERFACILITY NUMBER:
366402567
ADMINISTRATOR:DORIS EKANEMFACILITY TYPE:
775
ADDRESS:10221-B TRADEMARK STREETTELEPHONE:
(909) 483-1310
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 45CENSUS: DATE:
07/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dave Jimenez, Associate DirectorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility regarding an incident the State Licensing was made aware of, from an outside agency relating to an incident that occurred with a former consumer of Inland Adult Developmental Center. LPA Prieto met with Associate Director Dave Jimenez to explain the elements of the visit. LPA Prieto stated, to Jimenez, that Licensing was made aware of an incident that occurred at the facility where an outside agency was hoping to discuss. LPA Prieto could not locate an incident report from the Day Program regarding and inquired whether or not an incident report was reported. LPA interviewed staff at the facility (S1. S2, S3, S4) and concluded that the incident was not reported to State Licensing. LPA made Jimenez aware that the facility will be cited regarding reporting requirements. Staff corrected the deficiency by conducting in service training. Plan of correction was completed as of today's visit.

A copy of this report was signed by LPA Prieto and Associate Director Jimenez and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
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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Document Has Been Signed on 07/18/2022 02:15 PM - It Cannot Be Edited


Created By: Javier Prieto On 07/18/2022 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: INLAND ADULT DEVELOPMENTAL CENTER
FACILITY NUMBER: 366402567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2022
Section Cited
CCR
82061(a)

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82061 (a) REPORTING REQUIREMENTS.
A written report containing the information specified in Section 82061(a)(2) shall be submitted to the licensing agency within seven days following the occurrence of the event.
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Facility to provide in service training to staff by Plan of Correction date (POC). Facility provided the appropriate training as required and POC was cleared as of today.
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The was regulation was not met be evidenced interviews that an incident report was not sent to Licensing within the required time frame
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Javier Prieto
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022


LIC809 (FAS) - (06/04)
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