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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880723
Report Date: 06/05/2025
Date Signed: 06/05/2025 07:51:49 PM

Document Has Been Signed on 06/05/2025 07:51 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ATIENZA RESIDENTIAL CAREFACILITY NUMBER:
331880723
ADMINISTRATOR/
DIRECTOR:		ARMSTRONG, CAROLINEFACILITY TYPE:
740
ADDRESS:1328 GALAXY DRTELEPHONE:
(951) 845-3565
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 4DATE:
06/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Irene Espinoza, Caregiver and Rosalinda Penilla, Caregiver.TIME VISIT/
INSPECTION COMPLETED:
08:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) LaVette Farlow and Edith Conchas arrived at the facility to conduct a case management visit for deficiencies observed during complaint visit for control number 56-AS-20250603100246.

LPAs observed, Licensee Caroline Armstrong, did not have chemicals locked and secured and inaccessible to residents in care.

LPA's observed during the tour that residents medication was found unlocked and not secured in the following areas; pantry, kitchen cabinets and in the garage in several boxes and bags in plain view and exposed as well as in the refrigerator.

LPA's observed sharps in the food pantry unlocked and not secured and accessible to residents.

LPA's after doing a records review of 3 residents, LPA's observed 3 out of 3 residents files were incomplete. They were missing signatures on the admissions agreement, physicians report, Needs and service plan, Emergency contact sheets , MARs, Preplacement appraisal information, personal rights, and Telecommunication device notification form.

LPA's observed licensee did not have updated LIC 500. The current staff personnel files were incomplete and missing the following documents; Health screening report, TB clearance, Personal Record, Personnel report, Criminal record, verification of training, statement acknowledging requirement to report suspected abuse of a dependent adult or elder. ***CONTINUED LIC809C***
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/05/2025 07:51 PM - It Cannot Be Edited


Created By: Lavette Farlow On 06/05/2025 at 02:59 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
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2025
Section Cited
CCR
87411(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 evidence by:
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Staff immediately was removed from facility. The licensee has agreed to obtain background clearance for S1 before allowing S1 to work at the facility and provide proof to LPA of S1 association/ clearance.
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Based on interviews with staff #1, LPA's Farlow and Conchas determined that the licensee did not obtain S! criminal backgorund clearnace prior to employment which poses an immeddiate health, safety and personal rights risk to residents in care.Deficiency will be issued
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Type A
06/06/2025
Section Cited
CCR87465(h)(2)(i)

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87465(h)(2) Centrally stored medication... locked in place that is not accessible to persons other than employees responsible....
(i)Prescription or medication which are not taken with resident upon termination of service...to be disposed of and destroyed by facility...not a resident.
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The Licensee has agreed to ensure all centrally stored medication is kept in a safe and locked place that is inaccessible to residents in care by POC date 6/6/25. All none current residents medications be properly dispose of by 6/19/25.
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Based on LPA's records review and observation, the licensee did not ensure all residents medication was centrally stored and kept safe and locked away and inaccessible to residents in care. LPA's also observed expired medications still in facility as well as medications from previous residents not centrally stored and locked and inaccessible 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 07:51 PM - It Cannot Be Edited


Created By: Lavette Farlow On 06/05/2025 at 04:14 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
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2025
Section Cited
CCR
87506(d)

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All residents records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.
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 Licensee agrees to update client files by POC date.
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Based On LPA's observation and record review licensee did not have updated client files which were missing pertinent documents missing signature on admission agreement, Physician Report, Needs and Service plan and Emergency contact.
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Type B
06/12/2025
Section Cited
CCR87412(a)(c)(g)

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Licensee shall ensure the personnel records are maintained on the licensee, administrator and each employee... (c)Licensee shall maintain in the personnel records verification of required staff training and orientation.(g) All personnel records... for review
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 Licensee agrees to update client files by POC date.
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Based On LPA's observation and record review licensee did not have updated staff files which were missing Personnel records, health screening report, Criminal record report, verification of training
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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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 07:51 PM - It Cannot Be Edited


Created By: Lavette Farlow On 06/05/2025 at 04:40 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
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2025
Section Cited
CCR
87309(a)

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Except as specified in subsection (b)the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches tools, sharp objects... locked storage.
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Licensee agrees to secure and maintain all sharps, knives, and chemicals in a safe secure locked area innacessible to residents by POC date.
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Based on LPA's observations sharps, knives and chemicals were seen in pantry, garage and bathroom unlocked, not secured and accessible to clients.
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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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 331880723
VISIT DATE: 06/05/2025
NARRATIVE
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LPA's observed 1 out of 2 staff had not been background or fingerprint cleared to work in the facility.

LPA's reviewed the compliance history and observed that the licensee was issued a deficiency on 11/6/2024, for not ensuring a background clearance was completed on present staff prior to working in the facility. This is a repeat violation within the last 12 months.

Based on today's observation and interview with caregivers the Licensee is cited for violation of Title 22, California Code Of Regulations. In addition, this violation posed an immediate health and safety risk to resident(s) in care. An immediate Civil Penalty of $600 is being assessed. If the deficiencies are not corrected by the following day or Plan of Correction dates, a civil penalty of $100 per day per violation begins and accrues until corrected. The licensee was also informed that an additional civil penalty may be assessed based on Health and Safety Code 1569.59

See LIC809, LIC809C, LIC809D, LIC421BG and appeal rights were discussed and provided to caregiver Caroline Armstrong. Signature on this report acknowledges receipt of appeal rights.

An exit interview was conducted, appeal right discussed and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC809 (FAS) - (06/04)
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