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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 06/03/2024
Date Signed: 06/03/2024 03:07:23 PM

Document Has Been Signed on 06/03/2024 03:07 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/
DIRECTOR:		ARMSTRONG, CAROLINEFACILITY TYPE:
740
ADDRESS:1328 GALAXY DRTELEPHONE:
(909) 792-3835
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 4DATE:
06/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Caroline Armstrong, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced case management visit to the facility. LPA met with Administrator Caroline Armstrong.

The purpose of today's visit was to deliver an Immediate Exclusion letter for an individual name Adam Barone to MS Armstrong. The exclusion of Mr Barone is based on a complaint of conduct inimical that has been substantiated.

LPA reviewed the exclusion letter with Administrator Armstrong, explaining that Mr Barone is not allowed to be present in the facility. Administrator Armstrong understands this immediate Exclusion and has agreed that Mr Barone cannot be allowed to work and/or live in a CCL Licensed facility and have contact with residents in any facility licensed by the California Department of Social Services.

Adam Barone was present during the visit. LPA Prieto hand delivered Immediate Exclusion letter to Mr Barone.

No deficiencies were cited this visit. An exit interviewed was conduct when this report and immediate Exclusion letter was discussed and provided to the Administrator Armstrong.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
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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