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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880723
Report Date: 08/29/2023
Date Signed: 09/07/2023 02:04:31 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
08/24/2023 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20230824170032
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: 1DATE:
08/29/2023
UNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Adam Brone-CaregiverTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff do not provide adequate care & supervision to prevent resident from wandering away from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Adam Brone staff member who was informed of the purpose of the visit and allegations.

During the interview Adam Brone stated resident 1(R1) did wonder out of the facility on 8/22/2023. He stated that he checked on R1 at 12PM, and when he returned at 12:15 PM he discovered R1 was no longer in the facility. He stated he toured the neighborhood to locate R1 and was unsuccessful. Adam stated he returned and called 911 to file a missing person’s report and after identifying himself and providing proof that he was a caregiver at the facility he was informed by the police where R1 could be located. R1 and Adam was picked up by the administrator Caroline Armstrong at San Gorgonio Hospital the same day 8/22/2023. LPA observed R1's facility file and it states R1 is a wanderer and after conducting the interviews with the 2 staff members the facility staff did not ensure the needs of resident with dementia were met because R1 was able to leave the facility without supervision.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20230824170032
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
VISIT DATE: 08/29/2023
NARRATIVE
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Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230824170032
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: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2023
Section Cited
CCR
87705(b)(2)
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Care of Persons with Dementia
Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:Safety measures to address behaviors such
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The licensee has agreed to provide additional training to all facility staff regarding the cited regulation and provide a written statement of understanding by the POC date of 8/30/2023.
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as wandering, aggressive behavior and ingestion of toxic materials.This requirement is not met as evidenced by: Resident 1 was missing from the facility and was reported to be found at San Gorgonio Hospital. R1 left the facility without staff's knowledge on 8/22/2023.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3