<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 07/19/2024
Date Signed: 07/19/2024 11:18:18 AM


Document Has Been Signed on 07/19/2024 11:18 AM - It Cannot Be Edited

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
, 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: 4DATE:
07/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Caroline Armstrong-AdministratorTIME COMPLETED:
11:17 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/19/2024 Licensing Program Analyst (LPA) Bernadette Allen arrived at the facility to conduct the annual inspection. LPA introduced herself and was allowed entry into the home by support staff Danica Reyes.

LPA asked Danica the census and she confirmed four (4). While having a conversation with Caroline Armstrong the administrator LPA observed Adam Barone walking into the main door entrance area. Adam turn around fast going back into room number four (4) located by the front entrance. Caroline was asked why is Adam at the facility, and she said Adam is currently a client. LPA informed Caroline that he was not allowed to be at any facility licensed by California Department of Social Services. LPA asked Adam was he a client and he never responded to LPA’s question, he mumbled something under his breath and left the facility. Caroline was informed again that Adam Barone cannot be allowed to work and/or live in any CCL Licensed facility and should not have contact with residents in any facility licensed by the California Department of Social Services.

Caroline was informed that on 6/3/2024 Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced case management visit to the facility and met with her and at that time she was issued an immediate exclusion letter and had agreed that Mr. Adam Barone cannot be allowed to work and/or live in a CCL Licensed facility and not having contact with residents in any facility licensed by the California Department of Social Services.
A deficiency was cited during this visit for not ensuring the health and safety of the residents in care by allowing an excluded individual into the facility licensed California Department of Social Services.

An exit interviewed was conduct when this report and immediate Exclusion letter was discussed and provided to the Administrator Caroline Armstrong.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/19/2024 11:18 AM - 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
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: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2024
Section Cited
CCR
87777(1)(g)

1
2
3
4
5
6
7
87777- Exclusions
(1) Health and Safety Code Section 1569.58 reads in part:
(g) A licensee's failure to comply with the department's exclusion order after being notified of the order shall be grounds for disciplining the licensee pursuant to
1
2
3
4
5
6
7
The licensee has agreed to contact the excluded individuals responsible parties for relocation of Adam Barone and she will write a statement of understanding of the immediate exclusion letter issued on 6/3/2024 and the regulation cited she was cited for on 7/19/2024.
8
9
10
11
12
13
14
Section 1569.50.This requirement is not met as evidenced by: Based on observation, interview and document review, the licensee failed to comply with the immediate exclusion order issued on 6/3/2024 which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14

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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2