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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 09/07/2023
Date Signed: 09/07/2023 01:48:53 PM

Document Has Been Signed on 09/07/2023 01:48 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:
09/07/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Caroline Armstrong-Administrator TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bernadette Allen met with administrator Caroline Armstrong at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 09/7/2023 at 1:23 PM to initiate a Case Management Office Visit.

LPA Allen requested that the Caroline Armstrong come to the office to sign an amended complaint investigation control number control number- 56-AS-20230824170032 that was conducted on 8/29/2023.

During the investigation LPA spoke with Carolyn Armstrong who stated she had not faxed the completed LIC-624 regarding resident 1 leaving the facility on 8/22/2023. Caroline was informed of the reporting requirements on 8/29/2023. Carolyn Armstrong was called on 9/5/2023 to confirm if the LIC-624 was submitted to the office, she stated the form had not been submitted to CCLD. During the conversation Carolyn was informed again of the reporting requirements and she was informed she would be cited for not reporting the incident that occurred on 8/22/2023 with Resident 1 within 7 days of an incident occurring based on the reporting requirements.

An exit interview was conducted where this report was discussed, and a copy of the report LIC809 and LIC809-D was provided to Caroline Armstrong at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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Document Has Been Signed on 09/07/2023 01:48 PM - It Cannot Be Edited


Created By: Bernadette Allen On 09/07/2023 at 10:34 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2023
Section Cited
CCR
87211(a-b)

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87211- Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident
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Caroline Armstrong will provide training to all staff members regarding reporting requirments and has agreed to provide a written statement of understanding of the cited regulations by the POC date of 9/12/2023 before the close of business.
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within seven days of the occurrence of any of the events specified This requirement is not met as evidenced by:
Caroline Armstrong or staff did not report that resident 1 left the facility without staff members knowledge.
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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 Clemons
LICENSING EVALUATOR NAME:Bernadette Allen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
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