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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 04/06/2023
Date Signed: 04/06/2023 01:17:41 PM


Document Has Been Signed on 04/06/2023 01:17 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:ATIENZA RESIDENTIAL CAREFACILITY NUMBER:
331880723
ADMINISTRATOR:ARMSTRONG, CAROLINEFACILITY TYPE:
740
ADDRESS:1328 GALAXY DRTELEPHONE:
(909) 792-3835
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 0DATE:
04/06/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Caroline Armstrong AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Bernadette Allen met with Licensee/Administrator Caroline Armstrong at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 04/6/2023 at 1:10 PM to initiate a Case Management Office Visit.

LPA Allen requested that the licensee come to the office to sign an amended complaint investigation complaint control number 56-AS-20221012161059 that was conducted on 3/28/2023.

An exit interview was conducted and a copy of this report and amended complaint was provided at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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