Integrated Care Communities - B1

Type of visit: Required - 1 Year

On October 09, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Maria Gaston, Lead Staff. LPA returned to complete the annual on 10/24/2025. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 20 Elderly Adults and is currently operating at a capacity of 15. Facility type, Elderly Adults (740). LPA Mixson toured the facility along with the Lead Staff, Juanita Gaston, and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The facility is a single-story multi building structure home located at 14295 Nason Moreno Valley CA 92555. Physical Plant: The facility phone number is (951) 601-9150 and it is operable. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations at. The bathrooms were clean, and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the PUB 475. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care at the time of this visit. Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean; the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit. Administrator informed LPA there were safety lights for night throughout the facility. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate with an expiration date of 06/13/2026. Emely Rodriguez. Records Reviewed Resident Files: LPA reviewed the following forms in the residents files, admission agreements, medical assessments, consent forms, weight records, and emergency information. Appraisal and needs and services plan. Immunization records, along with the TB test. Records Reviewed Staff files: LPA requested and reviewed the following items for the staff records; First Aid, fingerprint clearances, abuse index, personnel records, health screenings, criminal record statements, employee rights, and TB test. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. There were no TA deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations at this time. An exit interview was conducted, and a copy of this report was discussed and given to Lead Staff, Juanita Gaston.the state’s words, verbatim · CDSS document, Oct 24, 2025

Allegation investigated: Facility failed to ensure a supply of resident's medication Facility failed to assist resident with administration of medications. Facility failed to inform responsible party that medication was not being administered.

On October 2, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Administrator Emely Rodriquez and the purpose of the visit was explained. Investigation consisted of the following: On 5/17/22, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. On October 1, 2025, the Department toured facility’s med room, requested and received copies of the following: Staff roster (dated 9/3/25) Resident Roster (dated 10/1/25), R1’s Medication Administration Record (MAR)-dated March 2022, April 2022, May 2022, R1 physician’s report (dated 2/17/22), Needs and Services Plan (dated 10/10/23), Medication audit sheet (dated 5/25/22), staff medication training (dated: 7/3/25, 6/25/25, 6/15/25, 5/30/25, 4/25/25, 4/9/25). The Department conducted interviews with 4 staff (S1-S4 ) and Administrator (A1). The Department interviewed 4 residents (R2-R5). Page 1 of 5 Unsubstantiated The investigation revealed the following: Allegation: Facility failed to ensure a supply of resident's medication. The detail of complaint alleges that there was a pharmacy change at the facility, and the pharmacy had trouble filling R1’s medication resulting in R1 only receiving 2 out of 9 of R1’ medications. On October 1, 2025, the Department obtained, reviewed and evaluated R1 Medication Administration Record (MAR) for March 2022, April 2022 and May 2022. Records revealed that all R1's medications, including PRNs were given and properly initialed by staff; no discrepancies found. Additionally, the records reveal there weren’t any lapses in medication administration during the specified time frame as indicated in the complaint. On October 1, 2025 at 9:35am, The Department interviewed Administrator (A1), who denied the allegation stating there were no reports of R1 missing medication as mentioned in the complaint. A1 went on to state that in the event a resident medication has not arrived due to any issue, the facility's pharmacy will provide them an emergency supply of medication until issue is resolved so that resident is not missing the medication. On October 1, 2025, between 10:00am and 11:00am, The Department interviewed 4 staff regarding the allegation and of those interviewed, 4 out 4 stated that at no time has R1 missed any of her medication. Additionally, 4 out of 4 stated that medications for all residents are dispensed as prescribed and are on time. Page 2 of 5 On October 1, 2025 between 11:00am and 12:00pm, the Department interviewed 4 Residents (R-2 -R5). The Department was unable to interview R1 as she reportedly moved out of facility on 12/31/24. No contact information provided. Of those interviewed, 4 out of 4 state they receive their medication as prescribed and on time and they have never missed medication due to staff not giving it. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. Allegation: Facility failed to assist resident with administration of medications. The detail of the complaint alleges that R1 had not received the medication for her depression and pain. On October 1, 2025, the Department obtained, reviewed and evaluated R1 Medication Administration Record (MAR) for March 2022, April 2022 and May 2022 in addition to the facility medication audit sheet (dated 5/25/22) which showed medication given and accounted for. Lastly, the Department also observed that any discontinued medication was properly noted on the MAR. On October 1, 2025, at 9:35am, The Department interviewed Administrator (A1), who denied the allegation stating medications are always given and there have been no reports of missed medication. Additionally, A1 expressed that if a resident’s medication runs out, “our pharmacy would give an emergency supply of medication so that Residents won’t miss their medication.” Page 3 of 5 On October 1, 2025, between 10:00am and 11:00am, The Department interviewed 4 staff regarding the allegation and of those interviewed, 4 out 4 stated that at no time has R1 missed any of her medication. Additionally, 4 out of 4 stated that medications for all residents are dispensed as prescribed and are on time. On October 1, 2025 between 11:00am and 12:00pm, the Department interviewed 4 Residents (R-2 -R5). Of those interviewed, 4 out of 4 residents state that they receive their medication as prescribed and on time and they have never missed medication due to staff not giving it. Based on the information gathered there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. Allegation: Facility failed to inform responsible party that medication was not being administered. The detail of complaint alleges that R1’s Responsible Party received an invoice from the pharmacy which showed that most of R1’s medications ran out March 19, 2022, and 1 other medication ran out April 4, 2022. On October 1, 2025, the Department conducted interview with A1 who denied the allegation stating that there was no missed medication, so there wasn’t a need to contact responsible party. A1 further explained that it is their practice to notify the responsible party if there are changes or if medications are “running low.” Lastly, A1 stated that not only do they inform the responsible party, but they also contact the resident’s Primary Care Physician. Page 4 of 5 The review of R1’s MARs was consistent with A1’s assertion of no missed medication during that time frame. Based on the information gathered there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted with Administrator Emely Rodriguez and copy of report provided. Page 5 of 5the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 18-AS-20220511152553

Type of visit: Case Management - Other

On January 10, 2025, Licensing Program Analysts (LPAs), Abdoulaye Zerbo and Seo Jeon did an unannounced visit to conduct a case management, and met with the Administrator Emely Rodriguez. LPAs introduced themselves and stated the purpose of the visit. LPAs toured the facility, along with the Administrator Emely Rodriguez, conducted interviews and made observations. The facility have three(3) staff per shift attending the residents' needs and conducting rounds every hour or more frequently if needed. There were no imminent health and/or safety concerns observed at the time of visit. LPAs did not observe any obstructions or debris inside or outside of the facility at the time of this visit. LPAs observed that the facility is using a generator as a source of power due to the outage. LPAs assessed the available food and observed sufficient food to be available for the residents in care. The food supply meets the requirement of a two-day supply of perishable foods and a seven-day supply of non-perishable foods. . The medications were found to be in sufficient supply, locked, and inaccessible to the residents in care. The facility is clean, and meets all the requirements for the residents in care. Based on the information obtained during today's visit, there were no immediate health and safety issues of the residents in care. An exit interview was conducted, and a copy of this report was provided to the Administrator, Emely Rodriguez.the state’s words, verbatim · CDSS document, Jan 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by the Administrator Emely Rodriguez notified her of the purpose for the visit and was allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single story building with 10 residents bedrooms, and 11 bathrooms. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in a kitchen cabinet and inaccessible to residents. The smoke detector and carbon monoxide detector were operational. LPA observed fire extinguishers to be in compliance with the department requirements and with an expiration date of 07/15/2025. LPA observed the hot water temperature to meet requirements at 107.1°F. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C..... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of June 10th, 2026 and a CPR certification with the expiration date of 06-25-26 Record Review and Resident/Staff Files: LPA reviewed files for Four(4) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Four (4) residents' files were reviewed and contained all required documentation. LPA observed resident files, to be stored in a locked cabinet in the office. The first aid kit was stored in a cabinet in the office. Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the medication room. LPA reviewed medications for six(6) residents, and noticed medications that were not punched out but marked as given to the resident. A citation will be issued Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 11-06-2024, which met department requirements. All facility exits were clear of obstructions. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Emely Rodriguez along with the appeal rightsthe state’s words, verbatim · CDSS document, Nov 27, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to follow up on a report of alleged abuse and neglect. The LPA met with Administrator, Emely Rodriguez, and informed her of the purpose for the visit. The LPA received a report, on 07/18/2024, of alleged verbal abuse by staff toward a resident in care. A report was also received on 07/18/2024 regarding staff members not answering the call system when a resident in care utilizes the pull cord in their bedroom. During the visit the LPA conducted staff and resident interviews, reviewed, and collected copies of relevant documentation. Three staff interviews reported having no knowledge of any staff members yelling at residents in care. Two staff interviews reported staff did have to speak to Resident One (R1) sternly after the resident was observed to be cussing when yelling at Resident Two (R2) on or around 07/17/2024. Staff interviews reported R1 frequently yells at other residents in care and staff intervene to discontinue the behavior. Four resident interviews were conducted; two residents reported staff have been observed to be yelling at residents while the remaining two residents reported they have never observed staff to yell at residents in care. Regarding the call system, one resident interview reported no occasion in which they have had to use the call system, while a second interview reported staff answer the pull cord within or under ten (10) minutes. Administrator Rodriguez was interviewed and reported no knowledge of the above concerns. No information was obtained, at the time of visit, to substantiate either allegation. This report was reviewed with Administrator Rodriguez and a copy was provided.the state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Required - 1 Year

On 11/16/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA met with Administrator, Emely Rodriguez and Relief Manager, Juanita Gaston who were informed of the purpose of visit. LPA toured the facility with Juanita Gaston. The following was observed, reviewed, and inspected: The physical plant, in general, was in good repair. The facility is operating in the capacity approved by Community Care Licensing (CCL). The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. LPA inspected a sample of resident bedrooms and bathrooms. Resident bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. Room temperatures were comfortable for residents in care. LPA inspected a sample of resident bathrooms; LPA observed bathrooms to be clean and sanitary. There is also a good number of personal toiletries available for the residents in care. LPA measured the hot water temperature in the sampled bathrooms, in which all bathroom sinks measured within regulation. Sampled bathrooms were equipped with non-skid surfaces and grab bars. Bedrooms were equipped with a pull cord system to notify staff of any emergencies. LPA toured the kitchen and dining area. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items that were labeled appropriately. The facility had a menu posted and available for review. Dishes, glasses, and utensils were in good condition and stored in a healthful manner. LPA inspected the common areas. Smoke detectors were last tested on 7/25/2023 by Costco. LPA observed several carbon monoxide alarms throughout the facility. Continue on LIC809 Continued from LIC809 There was a locked and centralized storage area for medications, including refrigerated medications. Medications appeared to be dispensed and documented appropriately. The facility had a designated area for resident files and staff files. All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Random staff and residents' records were reviewed. All required postings were posted near the entryway and throughout the facility. There was adequate seating in the common areas and several activity rooms. LPA observed several activity posters. The facility was also equipped with a complete first aid kit as well as the first aid manual. LPA inspected the outdoor area of the facility. There was shaded area with seating. Overall, the facility was clean, in good repair, and operating in safe conditions for residents in care. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Emely Rodriguez.the state’s words, verbatim · CDSS document, Nov 16, 2023