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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 10/01/2024
Date Signed: 10/01/2024 03:35:34 PM


Document Has Been Signed on 10/01/2024 03:35 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: 4DATE:
10/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Danica Reyes-TIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA) Bernadette Allen and Magda Malcore conducted an case management visit based deficiencies observed on July 17, 2024. LPA Bernadette Allen conducted a annual inspection and during this visit, the following deficiencies were observed:

During the inspection LPA requested files for staff members Caroline Armstrong and Danica Reyes that could not be provided. LPA also requested files for the resident 1(R1), Resident 2 (R2), Resident 3 (R3) and Resident 4(R4) that could not be provided or was incomplete. Armstrong left for work and allowed Danica to continue inspection process and sign report.

Staff Danica Reyes looked through documents, but she was unable to provide any files for staff members or residents.

LPA also observed the the licensee has not complied with the requirements for the fire clearance. An immediate civil penalty has been issued.

LPA requested Special Incident Reports for R1 and R4 that could not be provided.

LPA will inform the licensee Caroline Armstrong that she will be called in for a non-compliance meeting at the San Bernardino Regional office.

The licensee Armstrong was not present during today's the visit.

An exit interview was conducted and discussed with Danica Reyes- Caregiver and a copy of the report LIC 809, LIC809-C and LIC809-D was provided at the conclusion of the visit with appeal rights.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
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 3


Document Has Been Signed on 10/01/2024 03:35 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: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2024
Section Cited
CCR
87202(a)

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 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 ......
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The licensee has agreed to relocate the resident in bedroom #3 to a bedroom that has been approved by fire marshalls.
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This requirement is not met as evidenced by: Based on LPA observation,and interviews, the licensee did not comply with the section cited above LPA observed R1 in bedroom #3 which was is not cleared by the fire department for non-ambulatory residents.
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Type B
10/01/2024
Section Cited
CCR87506(a)-(e)

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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.This requirement is not met as evidenced by:
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The licensee has agreed to provide a complete files R1, R2,R3 and R4.
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Based on LPA observation,and interviews, the licensee did not comply with the section cited above LPA request facility files for R1,R2,R3 and R4 that could not be provided or was incomplete for review.
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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: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 10/01/2024 03:35 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: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited
CCR
87412(a)-(h)

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (h) All personnel records shall be retained for at least three (3) years
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The licensee has agreed to provide a complete file for all staff members eligible to work at the facility by the POC date.
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following termination of employment....This requirement is not met as evidenced by: During the visit LPA Allen requested personnel files that could not be provided.
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Type B
10/01/2024
Section Cited
CCR87211(a)-(b)

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(a)-(b)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days ......
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The licenss has agreed to provide SIR for the death of R1 by the POC date.
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This requirement is not met as evidenced by:LPA requested the special incident report (SIR) for R1 that could not be provided during visit.
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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: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3