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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880570
Report Date: 10/28/2023
Date Signed: 10/28/2023 06:37:18 PM

Substantiated


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
04/30/2021 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 18-AS-20210430090536
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:
10/28/2023
UNANNOUNCEDTIME BEGAN:
05:51 PM
MET WITH:Lavonne Brinley TIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Staff are mismanaging medications.
Staff do not have appropriate training.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to deliver the findings for the allegations listed above. LPA met with Administrator Ana Pleitez Stark who left during the visit and gave her care staff Lavonne Brinley approval to sign report.

The investigation consisted of interviews with two (2) staff members who stated that they have not been documenting the MAR for the clients in care.The administrator has also confirmed that accurate documentation has not been conducted per CCL requirements. The interviews also revealed that the licensee has not been conducting any quarterly or annual training for the staff and proof of training could not be provided at the time of the visit.

Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023
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-20210430090536
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2023
Section Cited
CCR
87411(c)(2)(B)
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87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual... (2) This training shall be...(B) Importance and techniques of personal care... This requirement is not met as evidenced by:
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Licensee has agrred to submit Proof of Required Trainings of all staff to LPA Allen by POC due date.
Licensee has agreed to submit a Signed Statement of Understanding on CCR 87411(c)(2)(B) by POC due date.
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Based on observations, interviews and record review, the Licensee did not comply with section cited above by having S2 and S3 worked at the facility without the required initial/annual training which poses immediate health, safety, and personal rights risk to resident in care.
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Type B
11/04/2023
Section Cited
CCR
87465(h)(6)
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87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications...(6) The licensee shall be responsible for assuring that a record... This requirement is not met as evidenced by:Based on observations, interviews and record review, the Licensee did not comply with section cited above by not
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The licensee has agreed to train all staff on CCR 87465(h)(6) and submit Training Log to LPA Allen by POC due date.
Licensee also agrees to submit a signed Statement of Understanding on CCR87465(h)(6) to LPAllen by POC due date.
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document in R1-R5 Medication Administration Record (MAR) the administration of any residents’ medications at the time they were given all pages were blank. This poses a potential health, safety and personal rights risk to resident 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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2