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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 04/03/2025
Date Signed: 04/03/2025 02:48:01 PM

Document Has Been Signed on 04/03/2025 02:48 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALTA LOMA GARDENS RESIDENTIAL CARE #1FACILITY NUMBER:
361880570
ADMINISTRATOR/
DIRECTOR:		STARK PLEITEZ, ANAFACILITY TYPE:
740
ADDRESS:6896 HELLMAN AVETELEPHONE:
(909) 244-9031
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 6DATE:
04/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ann Margarita Pleitez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Alta Loma Gardens Residential Care #1, Residential Care Facility for the Elderly unannounced, to conduct the Annual Inspection. LPA met with Administrator, Margarita Pleitez; introduced self and stated purpose of the visit. LPA was invited inside facility and provided space to work.

The current census is 6. The facility is licensed and approved for 6 non-ambulatory residents, 1 resident may be bedridden and Hospice Waiver for 4 residents. During the visit, LPA was accompanied on a tour of the facility and observed the following:

Physical Plant: The facility is maintained at a comfortable temperature. Pathways inside the facility were free of clutter and obstructions. The common areas such as Living and Dining areas provide adequate seating and lighting. Resident Rooms included adequate lighting, seating, beds with required linens, night stands and appropriate storage. Resident Bathrooms contained adequate paper supplies, space, hand soap, non-slip materials and operable appliances. Water temperature was tested and observed at 117.4 and 121.5 degrees F. The facility does have a notice posted caution hot water, in the residents restroom. The facility is equipped with operating smoke detectors and carbon monoxide alarms. LPA observed two fully charged fire extinguishers. 1 of the 2 fire extinguishers did not have tag of last inspection, which was dated 4/2024. LPA observed that items such as cleaning supplies, toxins, sharps, and other dangerous items were kept secure inaccessible to residents in care. The facility food supply was observed in good standing and sufficient for the amount of residents in care. Dishes, cups, and utensils were also observed and stored properly. Posters such as: Facility License, Facility Sketch, Long Term Care Ombudsman, See Something Say Something, Theft and Loss Policy, Administrator Certificate, and Resident Rights were posted in a prominent place in the facility. LPA observed Medications are kept secure and inaccessible to unauthorized individuals inside the facility kitchen. During the tour LPA observed medication in the garage that was not centrally stored and locked. The administrator stated it was medication from a resident that is no longer in the facility. Although the medication was inaccessible to residents it was not properly destroyed. A technical violation was issued.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570
VISIT DATE: 04/03/2025
NARRATIVE
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Yards/Outside: One shaded patio, with sufficient number of chairs for residents in care. The backyard is free of any bodies of water. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA observed that 3 out of 4 staff members working in the facility have criminal record clearance through the department. One staff member background clearance is in process and not cleared. A deficiency with civil penalty was cited.

Record Review: LPA reviewed 3 out of 3 resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed 2 out of 3 residents were missing the physician report, and needs and service plans. LPA requested 4 staff files. LPA was reviewing the files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPA observed the administrator did not have a file available for review. Also, 2 out of 3 staff were missing health screening, TB test, application an job description. Medications were audited at random and LPA observed the MARS is not accurately maintained. LPA reviewed the record and observed missing signatures, and date medication was issued, and facility did not have accurate records of which medication are being dispensed by staff. The review of the records revealed medications were not listed on the MARS. LPA observed the facility does not maintain an accurate file for 3 out of 3 residents. Also, LPA reviewed the facility's insurance coverage, emergency disaster plan, infection control plan and emergency drills. LPA observed the facility is not conducting quarterly fire and emergency drills. A deficiency was cited.

Five deficiencies, two technical violation, one technical advisory, and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC9102TA, LIC421BG, and appeal rights were discussed and copies were provided to the Caregiver AJ Espino.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/03/2025 02:48 PM - It Cannot Be Edited


Created By: Lavette Farlow On 04/03/2025 at 01:42 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 4 personnel records by not ensuring health screening, training records,TB test, job description, and application are in the personnel files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Licensee agrees to update and complete personnel records for herself and all staff working in the facility to ensure all required documents are in the file. The following items shall be included but is not liimited to these items: Health screening, criminal background, TB test, Training, CPR/First Aid Cert, Job description, application, etc, by POC date.
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 staff records, by not ensure a backgroung clearance was completed and current which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2025
Plan of Correction
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LIcensee agrees to ensure that all staff will complete a background clearance prior to working with resident in care. Licensee will immediately remove the one staff that is not clearance and replace with a cleared caregiver until such clearance is completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/03/2025 02:48 PM - It Cannot Be Edited


Created By: Lavette Farlow On 04/03/2025 at 01:42 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 3 resident MARS by not ensuring the record was accurate, medication are log, staff are signing and dated when medication is issued which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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Licensee agrees to conduct a training for all staff that assist with medications, for the procedures of logging, dating, maintaining medication, storage, and securing such items. Licensee will ensure all staff understand and review the regulation by POC.
Type A
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 3 resident in care by not ensuring each resident have a current physician report, and needs and service plan on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee agrees to schedule all resident in care with their appointed doctors to complete a LIC602. Licensee agrees to maintain and update annually the resident LIC602, and needs and service plan. Licensee agrees to complete this within 30 days for the LIC 602, and needs and service plan by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 04/03/2025 02:48 PM - It Cannot Be Edited


Created By: Lavette Farlow On 04/03/2025 at 01:42 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensure the facility is conducting quarterly fire and emergency drill which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Licensee agrees to maintain and conduct monthly or quarterly fire and emergency drill effective 4/4/2025. Licensee agrees to keep a separate log which show proof of staff and residents in attendance. These drills shall be conducted at varies times of the day (morning, afternoon, and night).
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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