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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402567
Report Date: 12/21/2021
Date Signed: 12/21/2021 01:31:56 PM

Document Has Been Signed on 12/21/2021 01:31 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: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:
12/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Dave Jimenez, Associate Executive DirectorTIME COMPLETED:
01:34 PM
NARRATIVE
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On 12/21/21, Licensing Program Analysts (LPAs) Anna Bueno and Bernadette Allen conducted an unannounced visit for the purpose of gathering details for an incident report provided to Community Care Licensing (CCL) by Doris Ekanem on 12/10/21.

On 12/10/21 at approximately 9 AM, Client 1 (C1) was being transported to the day program by Staff 1 (S1) on 12/10/21. Another vehicle caused S1 to brake quickly, which caused C1 to fall out of their wheelchair. C1 landed on their left shoulder/arm. C1 was not securely fastened in the wheelchair seatbelt. S1 phoned program director Ekanem and Ekanem and Staff 2 (S2) arrived at the scene of the accident. Ekanem, S1, and S2 assisted C1 back into their chair. Ekanem assessed C1 who did not appear to have any visible wounds, cuts, or abrasions. C1's responsible party (RP) was contacted and allowed C1 to return to day program. When S1 returned C1 to their home after progam, RP informed S1 that C1 was not right and RP will be taking C1 to the hospital.

On 12/11/21, RP contacted Ekanem to notify her that C1 had fractured their right hip in two places and their neck as a result of falling out of the wheelchair on 12/10/21. On 12/12/21, RP contacted Ekanem and provided an update on C1's injuries. C1 had fractured the right and left hip, with the right hip being broken in two places. C1 had hip surgery on 12/13/21 and was assessed for a neck surgery on 12/21/21. The facility conducted an internal investigation on 12/14/21 through 12/15/21 and S1 admitted that while they secured the wheelchair, they did not check whether C1's seatbelt was secured.

Based on LPAs observations and interviews, a citation will be issued during today's visit. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC809D. An exit interview was conducted where this report, 809D, LIC 811 and appeal rights were provided to Mr. Jimenez.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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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Document Has Been Signed on 12/21/2021 01:31 PM - It Cannot Be Edited


Created By: Anna Bueno On 12/21/2021 at 01:09 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
RIVERSIDE, CA 92507

FACILITY NAME: INLAND ADULT DEVELOPMENTAL CENTER
FACILITY NUMBER: 366402567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2021
Section Cited
CCR
82072(a)(2)

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Personal Rights: (a) Each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Licensee shall provide in service training to all staff. Licensee shall provide proof of training to the Department no later than POC date 12/22/21.
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This requirement was not met as evidenced by:
Per interviews, S1 stated that they did not check whether C1's seatbelt was secured while securing C1's wheelchair
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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:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
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