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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 04/22/2026
Date Signed: 04/22/2026 02:58:16 PM

Document Has Been Signed on 04/22/2026 02:58 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:
04/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Ana "Margarita" Pleitez, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On 4/22/2026 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, Ana 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 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, hand soap, non-slip materials and operable appliances. Water temperature was tested and observed at 121.3, 121.2, 126.2 and 124.2 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. At 10:38 AM, LPA observed that the first bathroom on the right side hallway under the sink had cleaning supplies that were not secured and accessible to residents in care. A Deficiency cited. LPA did observe a lock cabinet in the kitchen under the sink with toxins, sharps, and other dangerous items 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 cabinet.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2026
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: 04/22/2026
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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 4 out of 4 staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed 3 out of 3 resident files for admission agreements, physician reports, and needs and services plans. LPA observed 1out of 3 residents were missing the physician report. A Technical Violation issued. LPA reviewed 3 staff files for Criminal Background Clearance, Health Screening, TB test results, training requirements, and CPR/First Aid Certificate. LPA observed 1 out of 3 staff was missing a health screen, but the personnel record did have the TB test results. A Technical Violation Medications were audited at random and LPA observed the MARS is accurately maintained. Also, LPA reviewed the facility's files for insurance coverage, emergency disaster plan, infection control plan and emergency drills. LPA observed the facility is not maintaining Liability insurance coverage, and the Emergency Disaster Plan (LIC610E) was not reviewed and update. A Deficiency and Technical violation issued.

During todays visit Two deficiencies, and three technical violation, were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, and appeal rights were discussed and copies were provided to the Caregiver LaVonne Brinkley.

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

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2026 02:58 PM - It Cannot Be Edited


Created By: Lavette Farlow On 04/22/2026 at 02:20 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: 04/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

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 ensuring the facility maintained Liability Insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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The Licensee agrees to review the regulation cite, and purchase the required Policy and provide proof to LPA by POC due date.
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 3 bathrooms by ensuring that all disinfectants were locked and stored and inaccessible to residents which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2026
Plan of Correction
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Licensee agrees to review the regulation with all staff and conduct a training and submit proof of the training to LPA by POC due 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: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2026


LIC809 (FAS) - (06/04)
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