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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 05/15/2023
Date Signed: 05/15/2023 12:09:08 PM

Document Has Been Signed on 05/15/2023 12:09 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: 6DATE:
05/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Licensee - Margarita StarkTIME COMPLETED:
12:10 PM
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On this day Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to amend a case management deficiency report issued on 05/04/2023. The deficiency was issued in relation to complaint number: 18-AS-20211223163003. LPA met with care staff Fidel Tabi and AJ Espino who phoned licensee Margarita Stark. Stark arrived shortly and was informed of the purpose of today's visit.
This facility is licensed to admit residents with Dementia and the facility submitted a Dementia care plan with its plan of operation at the time of licensure.
The deficiency CCR 87208(c) issued on 05/04/23 is therefore invalid.

The deficiency for incomplete records CCR 87506(b) is still in place. During today's visit, LPA reviewed records and received proof of correction for all residents. A Letter of Deficiency Citations Cleared was issued during today's visit.

An exit interview was conducted where this report was discussed with and provided to Licensee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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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