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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 05/07/2021
Date Signed: 05/07/2021 02:44:37 PM

Document Has Been Signed on 05/07/2021 02:44 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALTA LOMA GARDENS RESIDENTIAL CARE #1FACILITY NUMBER:
361880570
ADMINISTRATOR:STARK PLEITEZ, ANAFACILITY TYPE:
740
ADDRESS:6896 HELLMAN AVETELEPHONE:
(818) 922-5427
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 5DATE:
05/07/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ana "Margarita" Stark - Licensee/AdministratorTIME COMPLETED:
02:30 PM
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An Informal Meeting was conducted today telephonically due to COVID-19 in order to discuss recent complaints received, recent concerns, and facility's overall progress and operation. Persons present at today’s meeting were: Licensing Program Manager (LPM) Joel Esquivel, Licensing Program Analyst (LPA) Crystal Colvin, and Licensee/Administrator Ana "Margarita" Stark.

Below are the topics that were addressed during the Informal Meeting Conference Call:

Recent Complaints

Staff Criminal Record Clearances

Reporting Requirements

Licensing Inspection Authority / Record Keeping

Administrator Duties / Supervision and Daily Operation at Facility

Licensee/Administrator Ana "Margarita" Stark agreed to bring the facility into compliance by 5/14/21, and to submit all outstanding requested records to LPA Colvin by this date. LPM Joel Esquivel and LPA Crystal Colvin offered the facility a referral to the Technical Support Program (TSP) Assistance. Licensee "Margarita" Ana Stark accepted the referral to the TSP Assistance.

An exit interview was conducted and a copy of this report was provided via email to Licensee/Administrator Ana "Margarita" Stark for signature. LPA Colvin additionally provided the Licensee with documents via email to get set up with the new Guardian Program for associating staff to the facility.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2021
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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