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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400985
Report Date: 08/15/2024
Date Signed: 08/15/2024 04:12:56 PM


Document Has Been Signed on 08/15/2024 04:12 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:ATRIA DEL REYFACILITY NUMBER:
366400985
ADMINISTRATOR:DEGUZMAN, SAMUELFACILITY TYPE:
740
ADDRESS:8825 BASELINE RDTELEPHONE:
(909) 989-4346
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:145CENSUS: 80DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Suby Kumar - Executive DirectorTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Executive Director Kumar. LPA explained the nature of today's visit. .

LPA accompanied with MS Kumar, conducted a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at resident bathrooms are within regulation. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detectors and carbon monoxide devices were tested by the Fire Department and found to be in working order. Inspection document was obtained. Facility sprinkler and kitchen sprinkler / extinguisher
systems were tested and found to be in working order.

Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods. Kitchen is well staff and aware of resident's specific dietary needs. Kitchen area is clean and sanitary.

Care and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. The facility is appropriately staff during night shift hours.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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 2


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: ATRIA DEL REY
FACILITY NUMBER: 366400985
VISIT DATE: 08/15/2024
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Administration: The last disaster drill was conducted on 2/15/2024. LPA did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation.

Medical Related Services: Prescriptions and non-prescription PRN medications contain a signed and dated written order from a physician. Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions.

No deficiencies cited. An exit interview was conducted where this report was provided and discussed with MS Kumar.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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