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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 11/06/2024
Date Signed: 11/06/2024 05:24:39 PM

Document Has Been Signed on 11/06/2024 05:24 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: 3DATE:
11/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Caroline Armstrong- Administrator TIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On 11/06/2024 at 09:50 AM, Licensing Program Analysts (LPAs) Bernadette Allen and Melody Brown conducted an unannounced Case Management visit. LPAs Allen and Brown met with Licensee/Administrator Caroline Armstrong. However, Licensee/Administrator Armstrong left the facility during the visit due scheduled resident assessment. Approval was given allowing staff member Danica Reyes to sign the report.

The purpose of the visit was to conduct an inspection to ensure ongoing compliance with regulations and laws and ensure the health and safety of residents in care. During the visit, LPAs Allen and Brown conducted a quick tour of the facility and reviewed documents. LPAs Allen and Brown observed the following and deficiencies were issued:
· LPAs Allen and Brown observed that Resident #3 (R3) does not have the required record of dosages of medications that are centrally stored.

· LPAs Allen and Brown observed that the facility does not have a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents.

· LPAs Allen and Brown observed that staffs at the facility are not assisting Resident #1 (R1), Resident #2 (R2) and R3 with their self administered medications per their physician’s order as there’s no record at the facility that indicated they are assisting R1. R2 and R3 self administered medication per their physician’s order.

· LPAs Allen and Brown observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.


· LPAs Allen and Brown observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) does not have the required dementia care training in hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 11:57 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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87468.2(20)

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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer ....
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The licensee has agreed to provide written notification of the transfer of R5 being moved to a new location in Redlands CA. Licensee has also agreed to provide written statement of understanding of the cited regulation by the POC date of 11/15/2024.
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This requirement was not met as evidenced by: Per Licensee/Administrator Armstrong and Resident #5 (R5) responsible party stated written notice of transfer was not given to them only verbal notification which poses a potential health, safety or personal rights risk to persons in care.
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


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Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 12:32 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87507(c)

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c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.
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The licensee has agreed to provided signed admissions agrements that must be signed by their responsible parties for R1 and R3.
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LPAs Brown and Allen observed Resident #1 (R1) and Resident #3 (R3) Admission Agreement do not have the required signature and signature date of R1 and R3 or their Representative.
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Type B
11/15/2024
Section Cited
CCR87457(a)(1)

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(a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. (1) Sufficient information about the facility and its services shall be provided to enable all persons involved in the placement to make an informed decision regarding admission.
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The licensee has agreed to provide the required preplacement appraisal (lic603) for R3 along with a written statement of understanding of the cited regulation by the POC date of 11/15/2024
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LPAs Brown and Allen observed that R3 does not have the required Preplacement Appraisal as evidenced of incomplete Preplacement Appraisal (LIC603) in R3 file.

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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 12:44 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
87465(6)

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87465 Incidental Medical and Dental Care (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility...This requirement was not met as evidenced by:
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The licensee has agreed to provide all residents required record of dosages of medications that are centrally stored and provide a written statement of regulations by the POC date of 11/7/2024.
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LPAs Brown and Allen observed that R3 does not have the required record of dosages of medications that are centrally stored which poses a potential health, safety or personal rights risk to persons in care.
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Type A
11/07/2024
Section Cited
CCR87705(c)(4)(A)

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c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415,..This requirement was not met as evidenced by:
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The licensee has agreed to to schedule a staff to work the night shift and submit an updated staff schedule or Personnel report (LIC500) showing a staff scheduled to work the night shift to LPA Allen on POC due date of 11/7/2024.
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LPAs Brown and Allen observed that the facility does not have a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents
which poses an immediate health, safety or personal rights risk to persons in care
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 01:08 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following...:This requirement was not met as evidenced by:
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The licensee has agreed to provide updated record of dispensing medications to each resident in care by the poc date of 11/07/2024
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LPAs Brown and Allen observed that staffs at the facility are not assisting R1, Resident #2 (R2) and R3 with their self-administered medications per their physician’s order as there’s no record at the facility that indicated they are assisting R1. R2 and R3 which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
11/15/2024
Section Cited
CCR87411(c)

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87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
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The licensee has agreed to provide proof of enrollment/registration for required annual training for all staff members. Licensee has also agreed to provide proof of training signed by all staff members once completed.
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LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. which poses a potential health, safety or personal rights risk to persons in care.
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 01:32 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
87705(c)(3)(A)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training
requirements in Section 87411(d), staff who provide direct care to residents with dementia ....
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The licensee has agreed to provide proof of enrollment/registration for required annual training for all staff members. Licensee has also agreed to provide proof of training signed by all staff members once completed.
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This requirement was not met as evidenced by:PAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required dementia care training in hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living. which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
11/07/2024
Section Cited
CCR87705(c)(3)(b)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training
requirements in Section 87411(d), staff....This requirement was not met as evidenced by:
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The licensee has agreed to provide proof of enrollment/registration for required annual training for all staff members. Licensee has also agreed to provide proof of training signed by all staff members once completed.
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LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not
have the required dementia care training in Recognizing the effects of medications commonly used to treat the symptoms of dementia.which poses an immediate health, safety or personal rights risk to persons in care
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 01:53 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
HSC
1569.695(e)(2)

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HSC 1569.695 Other Provisions (e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.This requirement was not met as evidenced by:
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The licensee has agreed to provide a completed copy of R3 current appraisal of resident needs and services plan for resident 3.
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LPAs Brown and Allen observed that Resident #3 (R3) does not have the required Needs and Services Plan maintained in R3 file.
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Type B
11/15/2024
Section Cited
CCR87411(g)(2)

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General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)...This requirement was not met as evidenced by:

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The licensee has agreed to ensure that all staff members are cleared and associated to the facility by providing proof of S3 associated through guardian.
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Based on interview with Staff #2 (S2), LPAs Brown and Allen determined that the Licensee did not ensure that Staff #3 (S3) criminal background clearance was transferred to the facility prior to employment which poses a potential and personal rights risks to residents in care.
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 02:26 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
HSC
1569.695(c)

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HSC 1569.695 Other Provisions (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios...
This requirement is not met as evidenced by:
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The licensee has agreed to conduct the required fire and eathquake drill at least on a quarterly basis and provide proof of current fire and earthquake drill by the POC date of 11/15/2024.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not conducting the required fire and eathquake drill at least quarterly which poses a potential health, safety or personal rights risk to persons in care
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Type B
11/15/2024
Section Cited
HSC1569.695(d)

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HSC 1569.695 Other Provisions (d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation ....This requirement is not met as evidenced by:
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The licensee has agreed to provide LPA a current emergency disaster plan that is required to be updated annually and signed by the administrator and provide a copy by the POC date of 11/15/2024.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the emergency disaster plan was reviewed annually and signed by the Administrator or Licensee which poses a potential health, safety or personal rights risk to persons in care.
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 8 of 14
Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 02:39 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87219(a)(1)

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CCR 87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participa-tion in planned activities. The activities made available shall include: (1) Socialization...This requirement is not met as evidenced by:
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The licensee has agreed to provide a schedule of planned activities at the facility for the socialization of residents in care. The licensee has agreed to provide a copy of planned activites by the POC date of 11/15/2024.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's planned activities at the facility for the socialization of residents and not just watching television at the living room which poses a potential health, safety or personal rights risk to persons in care.
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 9 of 14
Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 02:44 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
87307(a)(2)(B)

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(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may...This requirement was not met as evidenced by:
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The licensee has agreed to relocate resident #3 back into bedroom #3 and provide proof that R3 was moved back into the room.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by using the family room area as the sleeping area for Resident #3 (R3) and the staff, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
11/07/2024
Section Cited
CCR87411(g)(1)

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(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or..This requirement was not met as evidenced by:
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Licensee has agreed to obtain a background clearance for S4 before allowing s4 to work at the facility and provide proof to LPA Allen of association/clearance,
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Based on interview with Staff #2 (S2) and Staff #4 (S4), LPAs Brown and Allen determined that the Licensee did not obtain S4 criminal background clearance prior to employment which poses an immediate health, safety and personal rights risk to residents in care. Deficiency will be issued
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


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Page: 10 of 14
Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 02:53 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
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 by the POC date of 11/7/2024.
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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 with Caroline Armstrong and resident S1 has been allowed at the facility on 11/3/2024 after receiving an exclusion letter.
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Type A
11/07/2024
Section Cited
CCR87411(c)

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87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidence by..
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The licensee stated that she will have all staff members trained/registered with the required first aid training and provide proof of training/certification on the plan of correction by the POC date of 11/7/2024
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Based on observations and record review the licensee didn't comply with the section above by not ensuring that staff 1, 3, 4.and 5 did not have appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


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Page: 11 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/06/2024
NARRATIVE
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 · LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do nothave the required dementia care training in recognizing symptoms that may create or aggravate dementia behaviors, including, but not limited to, dehydration, urinary tract infections, and problems with swallowing.
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LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required dementia care training in Recognizing the effects of medications commonly used to treat the symptoms of dementia.
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LPAs Brown and Allen observed that Staff #1 (S1), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required training in first aid from persons qualified by such agencies as the American Red Cross.
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LPAs Brown and Allen observed that Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required health screening maintained in their facility file.
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LPAs Brown and Allen observed that Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required tuberculosis (TB) test and TB test result maintained in their facility file. Deficiency will be issued.

Based on interview with Staff #2 (S2) and Staff #4 (S4), LPAs Brown and Allen determined that the Licensee did not obtain S4 criminal background clearance prior to employment. Deficiency will be issued.

LPAs Brown and Allen observed the Licensee uses the family room in main common area as the sleeping area for Resident #3 (R3) and the staffs.

LPAs Brown and Allen observed Resident #1 (R1) and Resident #3 (R3) Admission Agreement do not have the required signature and signature date of R1 and R3 or their Representative.

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

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/06/2024
NARRATIVE
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· LPAs Brown and Allen observed that R3 does not have the required Preplacement Appraisal as evidenced of incomplete Preplacement Appraisal (LIC603) in R3 file.
· LPAs Brown and Allen observed that Resident #3 (R3) does not have the required Needs and Services Plan maintained in R3 file.
· LPAs Brown and Allen determined based on interview with Staff #2 (S2) that the Licensee did not ensure that Staff #3 (S3) criminal background clearance was transferred to the facility prior to employment.
· LPAs Brown and Allen observed that the facility’s not conducting the required fire and earthquake drill at least quarterly.
· LPAs Brown and Allen observed that the emergency disaster plan was reviewed annually and not signed by the Administrator or Licensee. Deficiency will be issued.
· LPAs Brown and Allen observed that there's no planned activities at the facility for the socialization of residents and not just watching television in the living room.

In addition based on interviews with staff and resident 2(R2) LPAs Allen and Brown obtained information that the excluded individual, Staff #6 (S6) was at the facility on 11/3/2024. A deficiency will be issued on 11/6/2024 and an immediate civil penalty of $1000.00 will be assessed for CCR 87777(a)(1)(g) as per documents reviewed the facility was cited for the same zero tolerance violation on 10/1/2024 and within the 12-month period.

An exit interview was conducted where this report. LIC809, LIC809C, LIC809D, LIC421IM, LIC421BG and Appeal Rights were discussed and provided to Caroline Armstrong Administrator/Licensee.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
Page: 13 of 14
Document Has Been Signed on 11/06/2024 05:24 PM - It Cannot Be Edited


Created By: Bernadette Allen On 11/06/2024 at 04:46 PM
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
87412(a)(11)

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87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.this requirement is not met as evidenced by...
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Licensee has stated to obtain S3,4,and 5 medical appointment to complete the required health screening report and submit proof to LPA Allen by the by the POC date of 11/7/2024.
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Based on observation interview and record review the licessee did not comply with the cited section above by not ensuring that staff 4,3,and 5 have the required health screening report maintained in s3,s4 and s5 files which poses an immediate health,saftey ,and personal rights risk to residents in care.
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Type A
11/07/2024
Section Cited
CCR87412(a)(12)

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87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General .this requirement is not met as evidenced by
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Licensee has stated to obtain S3,4,and 5 medical appointment to complete the required Tuberculousis (TB) report and submit proof to LPA Allen by the by the POC date of 11/7/2024.
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Based on observation interview and record review the licessee did not comply with the cited section above by not ensuring that staff 4,3,and 5 have the required Tuberculousis (TB) test and TB test results maintained in s3,s4 and s5 files which poses an immediate health,saftey ,and personal rights risk to residents in care.
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


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