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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880724
Report Date: 10/02/2024
Date Signed: 10/02/2024 10:48:05 AM


Document Has Been Signed on 10/02/2024 10:48 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:
361880724
ADMINISTRATOR:ARMSTRONG, CAROLINEFACILITY TYPE:
740
ADDRESS:911 HARTZELL AVETELEPHONE:
(909) 792-3835
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY:6CENSUS: 4DATE:
10/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Rosalinda Antonio Penela-Support StaffTIME COMPLETED:
11:00 AM
NARRATIVE
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On September 17, 2024, LPAs Bernadette Allen and Lavette Farlow conducted an unannounced visit to investigate COMPLAINT CONTROL NUMBER: 56-AS-20240911092746 and during this visit, the following deficiencies were observed:

During the investigation LPA requested files for staff members Rosalinda Antonio Penela and Carmelita Belveder Dedivas that could not be provided. LPA also requested files for residents R1, R2, R3, and R4 which were incomplete or could not be provided.

LPA requested the special incident report LIC624 for the death of R1 which could not be provided during the visit. LPA informed the licensee by phone and support staff that Incident reports are required within 7 days of each occurrence.

LPAs also observed medications were not in their original packaging and was being transferred between containers.

LPA verified prior to the visit that the facility fees are not current and must be paid in full.

Based on interviews and observations, citations will be issued for the licensee not having staff associated/cleared to work in the facility, not reporting incidents of the residents in care, for not having files for residents or staff members, for not having facility fees paid and for transferring medications between containers.

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

An exit interview was conducted where this report was discussed and provided to staff member Rosalinda Penela 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: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
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 10/02/2024 10:48 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: 361880724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2024
Section Cited
CCR
87506(a)-(e)

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(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
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The licensee has agreed to provide complete files for R1, R2,R3 ,R4 The administrator has also agreed to provide a written statement of understanding of the cited regulation.
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This requirement is not met as evidenced by: LPA request files for resident 1, 2, 3, & 4 that could not be provided or the file was not complete for review. This is a potential health and safety risk for residents in care.
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Type B
09/30/2024
Section Cited
CCR87211(a)-(b)

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87211 Reporting Requirements
(a) 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 .....
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Licensee has agreed to provide incident reports for R1 and R4. The administrator has also agreed to provide a written statement of understanding of the cited regulation signed by all staff members.
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This is requirement is not being met as evidenced by: LPA requested special insident reports for R1 and R4 and there were no reports available for review.
This is a potential health and safety risk for residents 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2024 10:48 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: 361880724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2024
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 following termination of
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The licensee has agreed to provide complete files for all staff members eligible to work at the facility. Administrator has also agreed to provide a statement of understanding of the cited regulation.
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employment....This requirement is not met as evidenced by: During the visit LPA Allen requested personnel files that could not be provided. This is requirement is not being met as evidenced by: S1 and S2 did not have a file for review. This is a potential health and safety risk for residents in care.
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Type B
10/07/2024
Section Cited
CCR87156(a)

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(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.
This is requirement is not being met as evidenced by: LPA noted that annual fees have not been paid.
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The licensee has agreed to pay facilitiy fees by the POC date and provide proof that fees have been paid.
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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: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/02/2024 10:48 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: 361880724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2024
Section Cited
CCR
87355(a)

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87355 Criminal Record Clearance
(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, resident...
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The licensee has agreed to prived proof of Criminal Record Clearance for Staff membersRosalinda Antonio Penela and
Carmelita Dadivas
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This requirement was not met as evidenced by: LPA observed two staff members who were not associated to the faciity.Rosalinda Antonio Penela and
Carmelita Dadivas did not have clearance or associated to the facility.
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Type B
10/07/2024
Section Cited
CCR87465(a)(5)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) Each resident's medication shall be stored in its
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The licensee has agreed to provide training to all staff members to ensure medications remain in it original packaging and provide a written statement of understanding of the cited regulation signed by all staff members.
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originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: LPA observed Residents medications were transferred between containerswhich poses/posed a potential health, safety or personal rights risk to persons 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4