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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880723
Report Date: 12/23/2024
Date Signed: 12/23/2024 12:09:43 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
12/18/2024 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241218154749
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: 3DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caroline Armstrong- AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff accepted Power of Attorney over resident
Staff are making medical decisions on behalf of a resident in care.
Staff altered a resident's document.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Administrator Caroline Armstrong and explained the elements of the complaint.Allegation #1: LPA Prieto obtained documentation that reveals staff member #1 (S1), associated with this facility, became resident #1's (R1) Power of Attorney (POA). An interview with Administrator Armstrong confirmed that S1 did indeed become POA for R1.Allegation #2: LPA Prieto obtained documentation showing that S1 altered R1's POA to include additional services and/or treatments. Administrator Armstrong confirmed in an interview that S1 is making medical decisions for R1.Allegation #3: Documentation (POA) for R1 was obtained, revealing that it was altered to include additional services and/or treatments. An interview with Administrator Armstrong confirmed these alterations.During the time of LPA's visit, there was one other resident in care (R2), who stated that he has his own responsible party who makes decisions related to R2's care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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-20241218154749
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: 12/23/2024
NARRATIVE
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Based on staff interviews and the documentation obtained, the allegations that staff accepted Power of Attorney over a resident, staff are making medical decisions on behalf of a resident in care, and staff altered a resident's document, were substantiated. This document, LIC 809, LIC 809D, and appeal rights were discussed with Administrator Armstrong, and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20241218154749
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: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2024
Section Cited
CCR
87217(d)(2)
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Safeguards for Resident Cash, Personal
Property, and Valuables
Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:accept any general or special power of attorney for any such person; This was not met was evidenced by:
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Administrator to remove staff #1, as POA for resident #1, and appoint an appropriated POA for R1 by POC date
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Documentation was obtained that reveals, staff #1 associated to the facility became POA for resident #1.
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Type A
12/30/2024
Section Cited
CCR
87207
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87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This was not met as evidenced by:
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Administrator to remove staff #1, as POA for resident #1, and appoint an appropriated POA for R1 by POC date
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Documentation was obtained that reveals, staff #1 associated to the facility became POA for resident #1 and altered such document to provide separate services and/or treatments
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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: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3