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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 12/16/2021
Date Signed: 12/16/2021 02:51:02 PM

Document Has Been Signed on 12/16/2021 02:51 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALTA LOMA GARDENS RESIDENTIAL CARE #2FACILITY NUMBER:
198603003
ADMINISTRATOR:STARK PLEITEZ, ANA MFACILITY TYPE:
740
ADDRESS:1667 WOODBEND DRTELEPHONE:
(818) 922-5427
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 4DATE:
12/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:S-1TIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a Case Management-Deficiencies visit during an initial 10-day complaint visit. LPA was allowed entry into this facility by Staff #1 (S-1).

During this visit, staff did not have access to facility Resident files nor facility Staff files. LPA only had access to Resident Hospice file(s), Staff notes file(s) and Residents Medication Administration Records (MARs). Additionally, LPA was informed that Staff #3 (S-3) began employment at this facility in January 2021. S-3 is not associated to this facility.

Deficiencies cited under California Code of Regulations, Title 22, Division 6 and Chapter 1, documented on LIC809D. Civil Penalties were assessed.

Exit interview was conducted, a copy of this report and Appeal Rights were provided to S-1

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/16/2021 02:51 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 12/16/2021 at 01:50 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #2
FACILITY NUMBER: 198603003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited
CCR
87411(g)(1)

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Personnel requirements:
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
Obtain a California clearance or a criminal record exemption as required by law or Department regulations
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The facility will ensure all staff members are fingerprint cleared and associated prior to working at the facility.

(1) The licensee will submit evidence staff has submitted to a live scan and have been associated by 12/17/21.
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This requirement was not met as evidenced by: The following staff was not associated to the facility (Oliver Velasco hired in January 2021).

Immediate Civil Penalties were assessed.
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Type B
12/20/2021
Section Cited
CCR87506(a)

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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff

This requirement was not met as evidenced by:
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License will ensure all required staff and resident files are maintained at the facility and are made available upon request. Licensee will submit a written statement as to how Licensee will comply with this regulation by to LPA Irra by POC due date of 12/20/21.
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Staff did not provide complete resident or staff files during a complaint visit.
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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:Christine Yee
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021


LIC809 (FAS) - (06/04)
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