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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410686
Report Date: 03/07/2025
Date Signed: 03/07/2025 03:42:33 PM

Document Has Been Signed on 03/07/2025 03:42 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 BOARD AND CAREFACILITY NUMBER:
366410686
ADMINISTRATOR/
DIRECTOR:		G CAYANAN/F CAYANANFACILITY TYPE:
740
ADDRESS:6368 MOONSTONE AVETELEPHONE:
(909) 941-8459
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 5DATE:
03/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:56 AM
MET WITH:Gina Cayanan, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaVette Farlow made an visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Staff, Lailani Pineda and was granted entry to the facility. Staff Lailani notified the administrator of my arrival. LPA was accompanied by Gina Cayanan to conduct a general overall inspection, which included, but was not limited to, the following:

The facility has 5 bedrooms, 2 1/2 bathrooms, I staff bedroom, kitchen, dining area, living room, laundry area, garage and backyard. LPA completed a walk through of facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). LPA observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 114.7, 121.7 and 120.7 degrees fahrenheit. LPA advised licensee to monitor the water temperature. A technical advisory issued. LPA observed the facility does not have operational smoke detector or carbon monoxide alarms. A deficiency was cited. LPA observed the facility was not equipped with operational fire extinguisher it was last purchased or charged on 2/13/2024. A deficiency was cited. LPA observed the facility has a first aid kit, the kit was missing a current first aid book.
LIC809 continued
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
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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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 BOARD AND CARE
FACILITY NUMBER: 366410686
VISIT DATE: 03/07/2025
NARRATIVE
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The first aid material was dated 2007. A technical violation was issued. Posters such as; the personal rights, CCL complaint poster, ombudsman, and license were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to residents. LPA observed the resident medication cabinet was not locked and observed the licensee remove resident medication from a cabinet with dishes and was unsecured. A deficiency was cited. LPA observed Residents/Staff files were observed in the staff office area and made inaccessible. There are no bodies of water, firearms or ammunition in the facility. LPA observed the living room area exit to the backyard was blocked and obstructed by walkers and lounge chair. LPA requested the those items be removed immediately due it being a safety hazard. A deficiency was cited. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Facility has a variety of food available. Dishes, cups, and utensils were stored properly.
Yards/Outside: One shaded patio, a side gate with entrance/exit to the facility the right side of the facility. Around 10:10AM, while touring the backyard LPA observed tree branches hanging very low blocking your ability walk freely. A deficiency cited. 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 the facility did not have a sufficient amount of hygiene product for residents in care, and some item are stored in staff common area. A technical violation issued. LPA observed the facility did not have a emergency to go bags for residents in care. A deficiency cited.
Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

LIC809C Continued

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC809 (FAS) - (06/04)
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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 BOARD AND CARE
FACILITY NUMBER: 366410686
VISIT DATE: 03/07/2025
NARRATIVE
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LPA reviewed 3 out of 3 staff files and all 3 files were incomplete, or missing health screening and training record and current CPR records. Technical violation issued. LPA reviewed and audited 2 out of 2 residents medication and the audit was complete and matched the MARS. LPA observed that the facility last reviewed the emergency disaster plan on 03/01/2025. LPA observed that the facility did not have a record of quarterly emergency drills. A deficiency cited.

Five (5) deficiencies and three (3) technical violations, and one (1) technical advisory were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC9102TA were discussed and copies were provided to Administrator Gina Cayanan.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 03/07/2025 03:42 PM - It Cannot Be Edited


Created By: Lavette Farlow On 03/07/2025 at 02:21 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 BOARD AND CARE
FACILITY NUMBER: 366410686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by maintaining a sufficiant number of carbon monixide detectors in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2025
Plan of Correction
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3
4
The Licensee agrees to purchase or change any batteries for the carbon monoxide detectors in the facility by POC date. LIcensee agrees to provide a statement acknowledging the regulation by POC.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above by ensuring the passageway in 2 out of 2 area are clear and free of obstruction for residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2025
Plan of Correction
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Licensee immediately removed the chairs, and walker inside the facility and on the patio. Licensee agrees to cut the branches to ensure a clear walk way by POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 03/07/2025 03:42 PM - It Cannot Be Edited


Created By: Lavette Farlow On 03/07/2025 at 02:21 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 BOARD AND CARE
FACILITY NUMBER: 366410686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 5 residents in care by not securing medication or destroying expired medication. The medication was removed from the kitchen cabinet during the inspection tour, which was not locked and secured, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee agrees to audit and ensuring that all medications for resident are secured and to maintain and disgard any expired medication for current resident, and discharged residents. Licensee agrees to send a statement acknowledging understanding and review of the regulation for herself and all staff.
Type A
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 5 out of 5 residents in care by not ensuring the facility maintained an emergency bag for each resident in care in case of evacuation, to include emergency face sheet with contact information of responsible parties, medication, clothing etc, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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LIcensee agrees to complete an emergency bag for each resident in care in case of evacuation with the required items stated by CCLD regulation 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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 03/07/2025 03:42 PM - It Cannot Be Edited


Created By: Lavette Farlow On 03/07/2025 at 02:21 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 BOARD AND CARE
FACILITY NUMBER: 366410686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

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 ensuring the facility conducted quarterly fire drill and maintained the fire extinguisher, charging the extinguisher, or ensuring the fire department check the status of the extingusiher, or purchased new fire extinguisher, or maintained a log as proof of the drill as stated by regulation, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee agrees to maintain a log for the fire drill and carbon monixide testing. Licensee agrees to purchase a new fire extinguisher or contact the fire department to certified the operations of the fire extingusiher. Licensee will conduct a training for the staff and provide a log for the next three months showing the drill have been completed. Providing proof of testing for the next three month starting March 10, 2025 and ending on June 7, 2025, and than proceeding to a quarterly schedule.
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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
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