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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 11/30/2022
Date Signed: 11/30/2022 11:29:42 AM


Document Has Been Signed on 11/30/2022 11:29 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: 0DATE:
11/30/2022
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee/Administrator Caroline ArmstrongTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown met with Administrator Caroline Armstrong at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 11/30/2022 at 10:30 AM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

During LPA Brown’s facility visit last 10/19/2021, LPA Brown requested for Staff 2 (S2) file and LPA Brown observed no staff file maintained at the facility and no record of S2 trainings completed at the facility. Staff 1 (S1) provided list of S2 trainings completed and LPA Brown observed that S2 had no Dementia Training as required and S2 only completed the required Dementia Training last 06/29/2022 per list of completed trainings provided by S1 to LPA Brown last 11/28/2022. LPA Brown will be issuing a deficiency for S2 providing direct care to R1 with dementia without appropriate training for the job assigned and as evidenced by safe and effective job performance as this pose immediate risk to residents in care.

LPA Brown reviewed facility's incident reports and LPA Brown did not find any Special Incident Report (SIR) that the facility submitted to Community Care Licensing Division (CCLD) to report R1's falls and LPA Brown will issue a citation for not reporting the incident at the facility as this pose potential risk to residents in care.

An exit interview was conducted where this report (LIC809), LIC80D and Appeal Rights were discussed and provided to Administrator Caroline Armstrong.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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 11/30/2022 11:29 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: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2022
Section Cited

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia ... (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training ... (A) Dementia care including, but not limited to... This requirement is not met as evidenced by:
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Based on interview and records review, the Licensee did not comply with the section cited above by not providing the appropriate Dementia training to S2 as required which pose immediate Health and Safety risk to the resident in care.
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Type B
12/07/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... This requirement is not met as evidenced by:
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Based on interview and records review, the Licensee did not comply with the section cited above by not submitting Special Incident Report (SIR) of R1's falls to CCLD ASC. This poses a potential Health and Safety risk to the resident in care.
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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