361880570-5-4-2023-18-AS-NBRN-CRPTYC-20230510150832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880570
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:13:14 PM

Unsubstantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2021 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211223163003

FACILITY NAME:	ALTA LOMA GARDENS RESIDENTIAL CARE #1		FACILITY NUMBER:	361880570
ADMINISTRATOR:	STARK PLEITEZ, ANA		FACILITY TYPE:	740
ADDRESS:	6896 HELLMAN AVE		TELEPHONE:	(909) 244-9031
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91701
CAPACITY:	6	CENSUS:	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:			TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident developed pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegation. LPA met with administrator Margarita Stark and informed her of the purpose of this visit. The investigation included interviews with relevant parties, records reviews, and observations of the physical plant. LPA was not able to interview Resident 1 (R1).

LPA was provided with an incomplete LIC 602, physician’s report, as it was missing pages 3 and 4 that included allergies, other conditions, physical health status, mental condition, capacity for self-care, and medication management. LPA received home health records from 10/1/2021 through 3/7/2022.

The allegation is R1 developed pressure injuries while in care. Interviews with relevant parties could not specify when R1 first moved into this facility however, Administrator stated that R1 moved in as early as January 2021 and moved out by 11/30/2021. Review of the LIC 602 state that R1 suffers from chronic venous ulcers and wound care is provided by a home health agency three times a week. Interviews with former caregivers and

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211223163003

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
, CA 92507

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1	FACILITY NUMBER: 361880570
	VISIT DATE: 05/04/2023

NARRATIVE

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wound nurse confirm that R1 is able to walk with an assistive device however R1 preferred to stay and sleep on their recliner. Home health recertification (11/8/21 visit) conducted by a registered nurse (RN) notes state that R1's skin was pink and dry with Stage 2 pressure ulcers on both buttocks, and present with stasis ulcers. Additionally, former wound nurse and caregiver interviews confirm that R1’s wound areas were consistently washed and dried by facility staff and cleansed by the nurse. Wound nurse continued to see R1 till 11/26/21 noting that the buttocks ulcers had no drainage or symptoms and/or signs of infection. Home health visit on 11/29/21 was completed by RN noted that the buttocks ulcers were in the similar condition from 11/26/21.

RN visited R1 at a new facility in another county. On 12/1/21 RN stated that the buttocks ulcers had no drainage or symptoms and/or signs of infection. RN visited R1 on 12/3/21 and noted same instruction about R1 staying in a recliner. Additional 12/3/21 notes state no open ulcers, buttock's ulcers are pink, no drainage and no signed and symptoms of infection.

Based on the above information, the allegation is therefore unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Margarita Stark.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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