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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 02/13/2023
Date Signed: 02/13/2023 11:05:11 AM


Document Has Been Signed on 02/13/2023 11:05 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: 5DATE:
02/13/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Corazon Capalad-Caregiver TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to interview resident and deliver findings on complaint CONTROL NUMBER 18-AS-20200625081458.


LPA Allen attempted to interview (R1) at the time of the visit but was unsuccessful.

An exit interview was conducted where this report was discussed and provided to Corazon Capalad at the conclusion of the visit and a copy was provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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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