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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880723
Report Date: 10/01/2024
Date Signed: 10/01/2024 03:20:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/24/2024 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20240924151149
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: 4DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Danica Reyes- CaregiverTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Excluded staff present in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Bernadette Allen and Magda Malcore conducted an unannounced visit to investigate and deliver the findings on the allegation above. LPAs met with Danica Reyes caregiver who was explained the purpose of the visit and allegation.

LPAs arrived at the facility approximately at 1:50 PM, LPAs toured the facility and observed Staff 1(S1) who has been excluded from the facility leaving out of the garage side door. The Interviews with residents, staff members, and the reporting party corroborated that S1 has been present at the facility since the exclusion order was issued on 06/03/2024.

LPA informed Danica Reyes- caregiver that the licensee will be called in for a non-compliance meeting at the San Bernardino Regional Office.
The caregiver and licensee has been informed that S1 needs to be disassociated from all facilities licensed by Department of Social Services.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20240924151149
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2024
Section Cited
CCR
87777(a)(1)(g)
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(a) The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59. Health and Safety Code Section 1569.58 reads in part:...
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The licensee is required to disassociate Adam Baron from gardian and must not allow him into any home licensed by Department of Social Services.
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(g) A licensee's failure to comply with the department's exclusion order after being notified of the order shall be grounds for disciplining the licensee pursuant to Section 1569.50.This requirement was not met as evidenced by: Based on LPAs and interviews S1 has been allowed at the facility after receiving an exclusion letter.
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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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20240924151149
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723
VISIT DATE: 10/01/2024
NARRATIVE
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Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated.
A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalties has been issued for the presence of an excluded person at the facility.

An exit interview was conducted where this report LIC9099, LIC9099-C and LIC9099-D was discussed and provided to Danica Reyes Caregiver at the conclusion of the visit with appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3