331880723-4-6-2023-56-AS-KCLS-CQSU6K-20230411151828

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880723
Report Date: 03/28/2023
Date Signed: 04/06/2023 01:18:58 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2022 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20221012161059

FACILITY NAME:	ATIENZA RESIDENTIAL CARE		FACILITY NUMBER:	331880723
ADMINISTRATOR:	ARMSTRONG, CAROLINE		FACILITY TYPE:	740
ADDRESS:	1328 GALAXY DR		TELEPHONE:	(909) 792-3835
CITY:	BEAUMONT	STATE: CA	ZIP CODE:	92223
CAPACITY:	6	CENSUS: 0	DATE:	03/28/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Adam Barone Support Staff		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility is not operating per fire clearance

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Bernadette Allen and Magda Malcore conducted an unannounced visit to deliver the findings on the above allegation. LPAs met with Adam Barone- Support Staff and explained the purpose of the visit.
The allegation: Facility is not operating per fire clearance. On 3/28/2023 LPA Allen arrived and met with Adam Barone and together we toured the facility. The tour included residents’ bedrooms to verify if the rooms are following the egress requirements for non-ambulatory residents. LPA observed that the rooms did not meet the egress requirements for non-ambulatory residents, and the door separating rooms 1 and 2 from the remainder of the living space should be permitted by the City of Beaumont Department of Building and Safety. Resident room 3 shall have a direct exit to the exterior in order to house non-ambulatory residents and the fire extinguishers shall be serviced annually.
Based on LPAs observation, interviews conducted and records review, the preponderance of evidence standard has been met. Therefore, the above allegation is Substantiated. This poses an immediate health, safety, risk to residents. LPA Allen informed the Adam of the corrections needed for compliance.
An exit interview was conducted with Adam Barone and a copy of this report, 9099D and appeal rights was provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20221012161059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 331880723
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/07/2023 Section Cited CCR 80020(a)(2)	1 2 3 4 5 6 7	80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee has agreed to address each concern of the Fire Marshal.(1)Permit from building and safty for door seperating room 1 & 2. (2) Door seperating rooms 1&2 from common living area should be solid wood 1 3/8 think,self closing or automatic closing by actuation of smoke detector and latch upon closing.
	8 9 10 11 12 13 14	The licensee did not comply with the City Of Beaumont Fire Marshal non-compliance order.	8 9 10 11 12 13 14	(3) Room 3 should have a direct exit to the exterior in order to have non-ambulatory clients. (4) Fire extinguishers require annual inspection. (5) Remove nigt chain the latch previously removed on 5/10/2022. During visit on 3/28/2023 the licensee corrected the above information and will provide the Marshals inspection notice. by the POC 4/7/2023 or before.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

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