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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 04/27/2022
Date Signed: 04/27/2022 02:00:23 PM

Document Has Been Signed on 04/27/2022 02:00 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:ATIENZA RESIDENTIAL CAREFACILITY NUMBER:
331880723
ADMINISTRATOR:ARMSTRONG, CAROLINEFACILITY TYPE:
740
ADDRESS:1328 GALAXY DRTELEPHONE:
(909) 792-3835
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 1DATE:
04/27/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator/Licensee Caroline ArmstrongTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 04/27/2022 at 12:45 PM, unannounced for a collateral visit on a complaint investigation to collect additional information regarding complaint control # 18-AS-20211012101603 and interview staffs. Upon arrival, LPA Brown met with Administrator/Licensee Caroline Armstrong for an interview, collected additional information and to discuss complaint allegations.

LPA Brown was unable to interview Staff 2 for additional information during this visit as identified on confidential list LIC 811.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided to Licensee/Administrator Caroline Armstrong.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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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