331880723-5-1-2024-56-AS-KCLS-D72Q38-20240710114816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880723
Report Date: 05/01/2024
Date Signed: 05/01/2024 11:37:34 AM

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
03/19/2024 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240319125953

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: 5	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Caroline Armstrong, Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff did not treat resident with dignity and respect.
Staff forcefully pulled on resident's body.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrives to the facility to initiate a complaint investigation regarding the above allegations. LPA Prieto met with Caroline Armstrong, Administrator, and allowed entry. The investigation consisted of staff and resident interviews and observations.

Regarding the allegation that staff did not treat resident with dignity and respect; LPA Prieto obtained video footage of the staff #1 (S1) retrieving resident #1 (R1) for a location outside the facility making statements to him that did not accord dignity in their personal relationships with staff and resident.

***continued on LIC 9099C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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-20240319125953

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: 05/01/2024

NARRATIVE

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Regarding the allegation that staff forcefully pulled on resident's body. ; LPA Prieto obtained video footage of the S1 retrieving R1 for a location outside the facility forcefully pulling R1 by the arms to retrieve and relocate R1 back to the facility.

Based on LPA observations, interviews which were conducted and records review, the preponderance of evidence standard has been met. Therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations Title 22 are being cited on the attached LIC 9099D).

This report was signed by LPA Prieto and Administrator Armstrong and a copy was left with the facility.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240319125953

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: 05/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/01/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 (a)(1) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator Armstrong stated that S1 will be terminated and disassociated from the facility as of today (5/01/24) and S1 will not be working with residents. Armstrong states an eviction will be issued for 60 to evict. Armstrong to email disassociation as of 05/01/24 to LPA Prieto.
	8 9 10 11 12 13 14	Video footage of the S1 retrieving R1 for a location outside the facility making statements to him that did not accord dignity in their personal relationships with staff and resident.	8 9 10 11 12 13 14
Type A 05/01/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 (a)(3) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature..This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator Armstrong stated that S1 will be terminated and disassociated from the facility as of today (5/01/24) and S1 will not be working with residents. Armstrong states an eviction will be issued for 60 to evict. Armstrong to email disassociation as of 05/01/24 to LPA Prieto.
	8 9 10 11 12 13 14	Video footage of the S1 retrieving R1 for a location outside the facility forcefully pulling R1 by the arms to retrieve and relocate R1 back to the facility.	8 9 10 11 12 13 14

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: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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