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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 08/29/2023
Date Signed: 08/29/2023 10:30:21 PM

Document Has Been Signed on 08/29/2023 10:30 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: 6DATE:
08/29/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Ana Stark Pleitez, administratorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted a subsequent unannounced annual inspection visit. LPA met with Administrator, Ana Stark Pleitez, who assisted with the visit. The facility is licensed to serve six (6) non-ambulatory residents who are ages 60 and above and approved for four (4) Hospice Waiver. Facility had dementia program on file. Currently, two (2) residents on hospice. Annual licensing fees are current. LPA discussed the purpose of today's visit with administrator.

The annual inspection consisted of interviews of staff/residents, use of CARE inspection tool, tour of the facility, review of food supply, review of medications, and reviews of staff/residents records.



The facility is a single story home located in a residential neighborhood, consisted of four (4) resident bedrooms, four (4) bathrooms, a kitchen, a dining room, a living room with TV and a garage, and indoor/outdoor activity areas. Resident bedroom #3 was a shared room with two residents residing there and had a divider at the middle of the room. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. Sufficient of linen supplies and personal hygiene supplies were observed. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility.

Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. Side and front yards are well maintained and free of debris. There is shaded outdoor area with ample seating. No bodies of water observed.
(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 198603003
VISIT DATE: 08/29/2023
NARRATIVE
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Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean. Plates, cups, glasses and utensils are sufficient for the current census.

Hot water temperature is in a range of 128.5 to 129.5 degrees Fahrenheit which was NOT within Title 22 Regulation guidelines. Exit doors are equipped with auditory device alarms.


Deficiencies were observed and cited per California Code of Regulations, Title 22. See LIC 809D for deficiencies.

An exit interview was conducted. This report is discussed and provided to Administrator, Ana, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document is an Amendment of Original Document on 02/14/2024 01:22 PM


Created By: Bonnie Tao On 08/29/2023 at 06:10 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
CCLD Regional Office, 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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance. ... prior to working, residing or volunteering in a licensed facility: (1) Request a transfer of a criminal record clearance.

This requirement is not met as evidenced by:
Staff #4 Mark Jeremy Barrica, DOB 08/31/91 was not associated with the facility and working at the facility.
Deficient Practice Statement
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Based on observation and file review, it poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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The facility will ensure that a criminal record clearance/exemption has been transferred and associated for all staff prior to working or being present at the facility.
Administrator would submit evidence to Licensing that a criminal record clearance transfer and association of an individual Mark Jeremy Barrica by POC due date on 9/5/23.
Type A
Section Cited
CCR
87303(e)(2)
Water temperature ..(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Hot water temperature is in a range of 128.5 to 129.5 degrees Fahrenheit which was NOT within Title 22 Regulation guidelines.
Deficient Practice Statement
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Based on observation and file review, it poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Administrator provided a daily water temperature log dated 8/30/23 and a weekly log, dated 09/05/23 to Licensing indicating water temperature was in a range of 105 - 120 degree Fahrenheit. POC due date 9/5/23.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/29/2023 10:30 PM - It Cannot Be Edited


Created By: Bonnie Tao On 08/29/2023 at 07:07 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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(d)
All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

This requirement is not met as evidenced by:
All resident files from resident #1 to resident #6 were missing consent forms, weight records, needs and service plan, and TB test results.
Deficient Practice Statement
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Based on observation and file review, it poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Administrator would have all residents files complete with consent forms, weight records, needs and service plan, and TB test results by POC due date on 9/5/23.
Type B
Section Cited
CCR
87412(f)
All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
This requirement is not met as evidenced by:
All staff files from staff #1 to staff#3 were missing Tb test results, 1st aide certificates, employee’s right and medical training verifications.
Deficient Practice Statement
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Based on observation and file review, it poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Administrator would have all staff files complete with Tb test results, 1st aide certificates, employee’s right and medical training verifications by POC due date on 9/5/23.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
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