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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880570
Report Date: 12/21/2021
Date Signed: 12/21/2021 12:10:22 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2020 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201201115558
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: 4DATE:
12/21/2021
UNANNOUNCEDTIME BEGAN:
11:30 PM
MET WITH:"Margarita" Ana Stark - Licensee/AdministratorTIME COMPLETED:
11:45 PM
ALLEGATION(S):
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Staff failed to notify resident’s authorized representative prior to resident signing document(s)
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of delviering findings for the complaint with the above allegation(s). LPA Colvin met with Licensee "Margarita" Ana Stark and advised them of the purpose of the visit. Below is a summary of the findings of the complaint.

Regarding allegation "Staff failed to notify resident’s authorized representative prior to resident signing document(s)": LPA Colvin conducted interviews and reviewed resident's (R1) facility file and Power of Attorney (POA) documents. Through interviews conducted, LPA Colvin confirmed that R1 signed paperwork for services for an outside person/agency, and that Licensee/Administrator had some knowledge of this agreement. However, through careful review of R1's most recent Physician's Report and POA document, LPA Colvin observed that R1 has what is known as a "Springing POA", which only becomes effective when R1 becomes incapacitated. In order for R1 to be declared incapacitated, R1 would need to be evaluated by a physician, who then makes a declaration on whether or not R1 is incapacitated. LPA Colvin did not observe any documentation in R1's file showing that this determination had been made.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20201201115558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #1
FACILITY NUMBER: 361880570
VISIT DATE: 12/21/2021
NARRATIVE
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Additionally, R1's POA has additionally acknowledged that R1 has not been evaluated or determined to be incapacitated, and therefore, the POA is not yet active. Therefore, based on interviews and record review, the allegation of "Staff failed to notify resident’s authorized representative prior to resident signing document(s)" is UNFOUNDED. This agency has investigated the complaint alleging "Staff failed to notify resident’s authorized representative prior to resident signing document(s)". We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator "Margarita" Ana Stark.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2