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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 12/15/2023
Date Signed: 12/15/2023 03:27:31 PM


Document Has Been Signed on 12/15/2023 03:27 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
SAN BERNARDINO, 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: 3DATE:
12/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caroline Armstrong, AdministratorTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visited based on complaint #56-AS-20231212113737 visit conducted on 12/15/23. LPA met with Administrator, Caroline Armstrong, and discussed the purpose of the visit.

During today's complaint visit, LPA was in the kitchen conducting an interview with the Administrator. Staff #1 (S1) was sitting in the living room which was located next to the kitchen. LPA observed (2) residents in the living room area.
While LPA was asking the Administrator questions, S1 shouted responses to LPA. LPA continued interviewing the Administrator when S1 again shouted responses to LPA. LPA stated to S1 that she was directing the questions to the Administrator. S1 loudly stated "I hate licensing" and said an inappropriate word in front of (2) residents in care. LPA asked S1 if the inappropriate word was directed to her. S1 loudly denied saying the inappropriate word. Administrator told S1 to leave the area. LPA stated to the Administrator that S1 is to leave the facility due to safety concerns for the residents. Administrator told S1 to leave the facility. S1 loudly stated "I'm leaving but I am coming back in 20 minutes!" During LPA's visit, S1 did not return to the facility.

LPA reviewed staff files for both staff #1 (S1) and staff#2 (S2). LPA record review revealed that the facility did not maintain staff telephone numbers, education and/or past employment history, and hours of training for both S1 and S2. The Administrator stated S1 had no previous employment history. The Administrator stated that S2 was transferred from another facility and will obtain her training history for licensing review.

Based on observations and record review, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted and copies of reports LIC809/LIC809-D with Appeal Rights were provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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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Document Has Been Signed on 12/15/2023 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2023
Section Cited
HSC
1569.269(a)(5)

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(a) Residents of residential care...shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings...this requirement is not met as evidence by:
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Licensee/Administrator shall conduct inservice training with staff on the regulation cited and submit proof of training by POC due date.
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Licensee/Administrator did not comply with regulation cited above by staff#1's inappropriate conduct in the presence of residents and Licensing Agency representative when poses an immediate health, safety or personal rights risk to persons in care.
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Type B
01/05/2024
Section Cited
CCR87412(a)

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not as evidenced by:
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Licensee shall submit to the licensing agency proof of missing documentation and/or employee application by POC due date.
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Licensee did not comply with section cited by S1 and S2 did not have personal telephone numbers, education and/or employment history on file for review; which is a potential health, safety, or personal rights rights to residents in care.
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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: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/15/2023 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87412(c)(1)(A)

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(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (1)The following...shall be documented:(A)For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...this requirement is not met as evidenced by:
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Licensee/Administrator shall submit to the licensing agency proof of staff training hours for licensing review.
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Licensee/Administrator did not comply with regulation cited above by hours of training for both S1 and S2 were not maintained in facility files; which poses a potential health, safety or personal rights risk to residents in care.
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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: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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