361880724-3-11-2025-56-AS-SRAZ-DENTDE-20250311143815

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880724
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:38:39 PM

Document Has Been Signed on 03/11/2025 02:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ATIENZA RESIDENTIAL CARE		FACILITY NUMBER:	361880724
ADMINISTRATOR/ DIRECTOR:	ARMSTRONG, CAROLINE		FACILITY TYPE:	740
ADDRESS:	911 HARTZELL AVE		TELEPHONE:	(909) 792-3835
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92374
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	03/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:17 AM
MET WITH:	Caregiver Rosa Penilla		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caregiver Rosalinda Penilla, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (4). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities, however after observation and interviews no planned activities are implemented; deficiency issued. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in one (1) resident bathroom measured 113 degrees F. Three (3) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, administrator certificate, facility sketch, emergency disaster plan and telephone numbers, CCLD complaint poster, and Ombudsman poster. Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient perishable food supply for residents in care, LPA observed expired non-perishable foods, deficiency issued. Sharps and chemicals were not kept locked and accessible to residents in care, deficiency issued. Continuation on LIC – 809C:

Karen Clemons	TELEPHONE: (951) 836-2784
Sarina Ramirez	TELEPHONE: (951) 248-0307
	DATE: 03/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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 03/11/2025 02:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE	FACILITY NUMBER: 361880724
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by having bleach unlocked under the sink in the bathroom and knives unlocked in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to train staff and send proof of POC to LPA by POC due date.

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by Staff #1 did not have a CPR certificate on file, as well as other caregivers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to send LPA all staff 's CPR certificates by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 836-2784
Sarina Ramirez	TELEPHONE: (951) 248-0307
	DATE: 03/11/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE	FACILITY NUMBER: 361880724
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87412(g)

Personnel Records

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having personnel records for Residents 2,3,&4 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to send proof of personnel records to LPA by POC due date.

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by staff #1 and #2 are not associated to facility on guardian which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to associate staff #1 and #2 to facility on guardian and submit proof to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 836-2784
Sarina Ramirez	TELEPHONE: (951) 248-0307
	DATE: 03/11/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2025 02:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE	FACILITY NUMBER: 361880724
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by having expired non perishable foods which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to toss out all expired foods, train staff, and submit proof of training to LPA by POC due date.

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having a Medication Administration Record which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to create a MAR for all residents, train staff, and submit proof of MAR and training to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 836-2784
Sarina Ramirez	TELEPHONE: (951) 248-0307
	DATE: 03/11/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2025 02:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE	FACILITY NUMBER: 361880724
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having admission agreements, pre admission appraisal, physicians reports for residents #2,3,4 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to submit proof of documents stated above to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 836-2784
Sarina Ramirez	TELEPHONE: (951) 248-0307
	DATE: 03/11/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2025 02:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE	FACILITY NUMBER: 361880724
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87219(a)

Planned Activities

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not offering activities for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to create an activites plan for residents and submit proof to LPA by POC due date.

Type B

Section Cited

HSC

1569.695(e)(1)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not having an updated resident roster which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Licensee has agreed to create a new resident roster and submit proof to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 836-2784
Sarina Ramirez	TELEPHONE: (951) 248-0307
	DATE: 03/11/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE	FACILITY NUMBER: 361880724
	VISIT DATE: 03/11/2025

NARRATIVE

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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff do not have current CPR/first aid training, deficiency issued.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet, no MAR or documentation showing when medication was administered, deficiency issued.

Record Review: Four (4) Staff files reviewed were observed to be incomplete, deficiency issued. Four (4) Resident files reviewed were observed to be incomplete, deficiency issued.

Based on observations and record review deficiencies and technical assistance were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report along with LIC 809D, LIC 902, and Appeal Rights were discussed and provided to Caregiver Rosalinda Penilla.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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