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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400985
Report Date: 03/21/2023
Date Signed: 03/21/2023 02:31:54 PM


Document Has Been Signed on 03/21/2023 02:31 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: 89DATE:
03/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Suby Kumar - Executive DirectorTIME COMPLETED:
02:32 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to request records for and deliver an amended allegation findings to complaint control number: 18-AS-20220126095612. LPA met with Executive Director (ED) Suby Kumar and Nicole Stinson, Resident Services Director.

RSD Nicole Stinson will provide records electronically no later than the endo of this week due to system and access changes from April 2022.
The allegation is Staff do not ensure resident takes medication and the amended finding is UNSUBSTANTIATED.

ED Suby Kumar signed the amended LIC9099. The report was discussed with and copies were provided to ED at the conclusion of today’s visit.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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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