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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 08/25/2021
Date Signed: 08/25/2021 11:27:11 AM

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: 0DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Adam Barone, CaregiverTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 10:15 AM, LPA was met by Caregiver Adam Barone and explained the purpose of the visit. Present in the facility during time of visit were one (1) staff as well as zero (0) residents. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility to verify any residents residing in the four bedrooms and two bathrooms, garage and no residents present. Caregiver advised that all questions on the Infection Control tool would need to be answered by the Administrator Caroline Armstrong. LPA left several messages for Administrator to return phone call. LPA observed proper signage throughout the facility and sufficient hand hygiene supplies. Bedrooms designated for residents contained hospital beds, incontinence supplies and clothing. There are insufficient PPE supplies. Caregiver advised the residents have passed away and the last resident in the home was a couple of weeks ago but has passed away. LPA obtained the names of the residents five (5), one resident was relocated to the facility in Redlands.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-0337
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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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