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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:16:51 PM

Document Has Been Signed on 05/04/2023 02:16 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
, CA 92507
FACILITY NAME:ALTA LOMA GARDENS RESIDENTIAL CARE #1FACILITY NUMBER:
361880570
ADMINISTRATOR:STARK PLEITEZ, ANAFACILITY TYPE:
740
ADDRESS:6896 HELLMAN AVETELEPHONE:
(909) 244-9031
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: DATE:
05/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
02:18 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to deliver findings to complaint number 18-AS-20211223163003. LPA met with Margarita Stark who was informed of today's visit.

During the investigation of the above mentioned complaint number, it was discovered that the facility did not have full records for R1 and that R1 was diagnosed with Dementia. This facility is not licensed to admit Dementia residents and this facility does not hold a dementia care plan. These pose an immediate health and safety risk to residents in care. Refer to LIC-809D for deficiency cited.

An exit interview was conducted with and a copy of this report, LIC809-D, and appeal rights were provided to
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/04/2023 02:16 PM - It Cannot Be Edited


Created By: Anna Bueno On 05/04/2023 at 12:17 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
87208(c)

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Plan of Operation - A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).
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Licensee shall submit to the Department a memorandum of understanding of sections 87208(c) and 87705 no later than then end of POC date.

Resident 1 has not lived at this facility since December 2021.
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This requirement was not met as evidenced by:

Resident 1 has a diagnosis of Dementia. This poses a potential health and safety risk to residents in care.
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Type B
05/12/2023
Section Cited
CCR87506(b)

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Resident Records - Each resident’s record shall contain at least the following information...

This requirement was not met as evidenced by:
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Licensee shall evaluate all resident records for accuracy and submit to the Department a memorandum of understanding of section 87506 no later than then end of POC date.
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Records received by LPA for Resident 1 are missing admissions agreement, hospice notes, incomplete functional assessment, and appraisal. This poses a potential health and safety risk to residents in care.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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