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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880724
Report Date: 09/19/2025
Date Signed: 09/19/2025 01:49:10 PM

Document Has Been Signed on 09/19/2025 01:49 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:
361880724
ADMINISTRATOR/
DIRECTOR:		ARMSTRONG, CAROLINEFACILITY TYPE:
740
ADDRESS:911 HARTZELL AVETELEPHONE:
(909) 792-3835
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 6CENSUS: 5DATE:
09/19/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Caroline ArmstrongTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sarina Ramirez and Mary Rico conducted a health and safety visit to the facility. LPAs met with Staff, Rose Penilla, and informed the purpose of the visit.

LPAs observed four (4) residents and two (2) staff at facility, one (1) resident was out in the community with S4. Based on record review S4 is not associated to the facility, citation and civil penalty issued. LPAs conducted a tour of the inside and outside of facility. The facility has sufficient food supply for residents, however LPA observed expired non perishable foods; deficiency issued. Air conditioning and bathroom equipment is running properly, however LPAs observed dirty water from the residents shower head and sink faucet. The facility does not have clean running water for the residents. In addition, the hot water measured over 120 degrees F, citation issued. Staff working stated that Adam Barone does not work or live at the facility.

Resident files were not available for review, citation issued. LPA observed roaches in the main hallway near the dining room, citation issued. After reviewing the facility's floor plan, LPAs observed the Licensee converted their living room into a staff bedroom. During staff interviews S1 and S2 confirmed they sleep in the living room. Furthermore, the Licensee also converted resident's room number 1 into a personal bedroom for Licensee family, citation issued. Based on record review family member/S3 does not have a criminal record clearance, citation and civil penalties issued.

An exit interview was concluded where this report, LIC 809D, LIC421BG, and Appeal Rights were discussed and a copy was provided to Administrator Caroline Armstrong at the conclusion of the visit.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2025
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 09/19/2025 01:49 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 09/19/2025 at 11:07 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
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 361880724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2025
Section Cited
CCR
87412(g)

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87412 Personnel Records
(g) All personnel records shall be maintained at the facility.
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Licensee has agreed to provide LPA with all required documents for all residents by the POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having personnel records for Residents 2,3,4,&5 which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/19/2025
Section Cited
CCR87555(a)

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87555 General Food Service Requirements (a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances ... All food shall be selected, stored, prepared and served in a safe and healthful manner.
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LPA had Caregiver toss the expired food LPA observed, Licensee has agreed to go through the rest of the pantry to toss out anymore expired non perishable foods and conduct a training for all staff and provide proof to LPA by due date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by having expired non perishable foods 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/19/2025 01:49 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 09/19/2025 at 11:30 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
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 361880724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee has agreed to call a pest control company to conduct an inspection and a plummer to inspect the facilities water and provide a schedules appointment along with an invoice to LPA by POC due date.
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Based on observation, the licensee did not comply with the section cited above, by having live crockroaches in the main hallway near the dining room and not ensuring resident shared bathroom is providing clean water which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/20/2025
Section Cited
CCR87303(e)(3)

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87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.
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Licensee stated to put a warning sign on tap water that delivers hot water above 125 degree F and submit proof to LPA by POC due date.
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Based on observation the licensee did not comply with the section cited above by not identifying tap water that delivers water above 125 degree F by warning signs which poses/posed a 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2025 01:49 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 09/19/2025 at 11:47 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
RIVERSIDE, CA 92507

FACILITY NAME: ATIENZA RESIDENTIAL CARE
FACILITY NUMBER: 361880724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2025
Section Cited
CCR
87307(a)

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87307 Personal Accommodations and Services (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 reside in the facility. The following provisions shall apply:
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Licensee has agreed to clean the living room and staff befroom to it's original state reflecting the floor plan.
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Based on observation and interviews, the licensee did not comply with the section cited above by using the living room and a residents' bedroom as a staff bedroom/living area which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/20/2025
Section Cited
CCR87303(2)

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87303 Maintenance and Operation(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained ...a temperature of not less than 105 and not more than 120 degree F.
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Licensee has agreed to adjust the water temperature to ensure it is in complaint of 105 to 120 degree F and provide proof to LPA by POC due date.
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Based on observation the licensee did not comply with the section cited above by not ensuring the hot water temperature maintained 105 and not more than 120 degree F which poses/posed a 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2025 01:49 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 09/19/2025 at 12:43 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: 361880724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2025
Section Cited
HSC
87355(e)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
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Licensee will obtain a background clearance for S3 and provide proof to LPA by POC due date.
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Based on observation, record review, and interviews the Licensee did not comply with the section cited above by not having a background clearance for S3
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Type A
09/20/2025
Section Cited
HSC87355(e)(4)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ...(4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.
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Licensee has agreed to associate S4 to the facility and provide proof to LPA by POC due date.
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Based on observation, record review, and interviews the Licensee did not comply with the section cited above by not having S4 associated to the facility
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
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