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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 11/08/2023
Date Signed: 11/08/2023 10:58:44 AM

Document Has Been Signed on 11/08/2023 10:58 AM - 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:
11/08/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Ana Pleitez Stark AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Bernadette Allen met with Ana Pleitez Stark Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 11/08/2023 at 10:50 AM to initiate a Case Management Office Visit.

LPA Allen requested that Ana Pleitez Stark come to the office to sign an amended complaint investigation control number 18-AS-20210430090536 that was conducted on 10/28/2023. The report was missing an allegation and investigation information.

An exit interview was conducted where this report was discussed, and a copy was provided to Ana Pleitez Stark at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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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