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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 07/31/2024
Date Signed: 07/31/2024 02:12:22 PM


Document Has Been Signed on 07/31/2024 02:12 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
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: 3DATE:
07/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Caroline Armstrong- Administrator TIME COMPLETED:
02:35 PM
NARRATIVE
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During the interview with Caroline she was asked how many residents were in her care and she said that she had a census of five (5) which included Adam Barone, but when obtaining files Caroline only had incomplete files for Resident 1(R1),Resident 2 (R2) and Resident 3 (R3). Caroline said that she had to leave and allowed her caregiver Danica Reyes to provide LPA with documents needed and to sign the annual report.

LPA observed Resident 1 (R1) in a bedroom that was not approved/cleared by the fire department for non-ambulatory clients in care. Per the approved fire clearance dated 3/30/2023 bedroom #4 is the only room approved for non-ambulatory residents which is currently being used by Caroline Armstrong-Administrator.

Medications are kept inaccessible to clients. Overall, the facility is clean and in good repair.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care.

Record Review: LPA reviewed (3) client files for admission agreements, updated physician reports, and needs and services plans .R1, R2 and R3 files were incomplete. LPA attempted to review files for staff member(s) but there were no files available for review.

Care & Supervision: Facility had sufficient care staff at the time of annual inspection. The staff members working in the facility had criminal record clearance through the department.

The annual inspection was completed on 7/31/2024 and the administrator Caroline Armstrong was called during the inspection. Caroline was asked if Adam Barone was still allowed to reside or allowed to enter the facility since receiving the exclusion letter and she stated Yes and he is being allowed to stay at the home because he is currently a client not a staff member.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
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 07/31/2024 02:12 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
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: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87506(a)-(e)
a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. LPA reviewed the files of the residents in care and each residents file were incomplete,invalid information or could not be located.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations,interview, record review, the licensee did not comply with the section cited above the licensee did not ensure that the residents files were not complete with information, invalid information and could not be located. This poses a potential health and saftey concern for the residents in care.
POC Due Date: 07/30/2024
Plan of Correction
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The licensee has agreed to xxxxx
Deficiency Dismissed
Type B
Section Cited
CCR
87156(a)(e)
(a) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license.
(e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews,and record review the licensee did not comply with the section cited above the licensee has been informed of past due facility fee's which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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The licensee has agreed to xxxxx
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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2024 02:12 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
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: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87204
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation,interview, and record review the licensee did not comply with the section cited above LPA observed R1 in bedroom #3 which was is cleared by the fire department for non-ambulatory residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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The licensee has agreed to xxxxxx
Deficiency Dismissed
Type A
Section Cited
CCR
87202(a)
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review the licensee did not comply with the section cited above the licensee has not complied with the fire clearance request made by the City of Beaumont fire Marshal dated May 10,2022 listing five (5) non-compliant orders issued which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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The licensee has agreed to xxxxx
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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 07/31/2024 02:12 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
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: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87516(a)(e)
(a) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license.
(e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above the licensee has not paid the past due annual fee's. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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The licensee has agreed to pay the annual fees in full by the poc date of 8/1/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


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
VISIT DATE: 07/31/2024
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Caroline was informed that fee's of $100 a day will be assessed from 6/3/2024 until Adam Barone is disassociated from the facility for not complying with the exclusion letter issued on 6/3/2024. Caroline was also informed that disassociation through Guardian is required to clear the plan of correction within 24 hours.
Caroline said that she will appeal because Adam is no longer a staff member.

Caroline was informed on 7/19/2024 annual fees were required to be paid and has not been as of 7/31/2024. Caroline was issued civil penalties for not paying past due annual fee's.

An exit interviewed was conduct where this report was discussed and provided to the Danica Reyes at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
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