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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 06/26/2020
Date Signed: 06/26/2020 12:02:53 PM

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:ATIENZA RESIDENTIAL CAREFACILITY NUMBER:
331880723
ADMINISTRATOR:ARMSTRONG, CAROLINEFACILITY TYPE:
740
ADDRESS:1328 GALAXY DRTELEPHONE:
(909) 792-3835
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 2DATE:
06/26/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Adminstaror Caroline Armstrong TIME COMPLETED:
09:25 PM
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Licensing Program Analyst (LPA) Elton Harps conducted an unannounced visit to conduct a health and safety inspection related to complain 18-AS-20200625081458.

LPA and facility administrator Caroline Armstrong toured the facility by using the state phone facetime app. LPA observed charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. LPA observed a sufficient amount of food on hand. LPA did not see any facility residents. Administrator Armstrong explained that there only two residents living at the facility but not present because they were hospitalized before medical evaluation. During this visit, LPA did not observe imminent health & safety concerns.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator Caroline Armstrong.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Elton HarpsTELEPHONE: (951) 217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020
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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