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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 11/03/2020
Date Signed: 11/03/2020 09:11:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALTA LOMA GARDENS RESIDENTIAL CARE #2FACILITY NUMBER:
198603003
ADMINISTRATOR:STARK PLEITEZ, ANA MFACILITY TYPE:
740
ADDRESS:1667 WOODBEND DRTELEPHONE:
(818) 922-5427
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 4DATE:
11/03/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Margarita Stark, LicenseeTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Linda Almaraz conducted a visit with the above facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this visit was conducted telephonically with Licensee, Margarita Stark.

During the visit, the Licensee did not provide LPA with Resident and Staff files. The following Staff members were not associated to the facility:

Lavonne Brinkly - Date of Hire 1/2020, Patricia Moreno -Date of Hire 11/2019, Robin Johnson -Date of Hire 8/2020, and Janie Adame -Date of Hire 8/2020.

It was also discovered 5 Residents have passed away since November 2019 and were never reported to CCL.

Deficiencies cited under California Code of Regulations, Title 22, Division 6 and Chapter 1, documented on LIC 809D. Civil Penalties were assessed.

Exit interview was conducted telephonically, Appeals right and a copy of this report was provided via email to Licensee.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #2
FACILITY NUMBER: 198603003
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2020
Section Cited

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Personnel requirements:
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
Obtain a California clearance or a criminal record exemption as required by law or Department regulations
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This requirement was not met as evidenced by: The following staff were not associated to the facility (Lavonne Brinkly - DOH 1/2020, Patricia Moreno -DOH 11/2019, Robin Johnson -DOH 8/2020, and Janie Adame -DOH 8/2020)
Immediate Civil Penalties were assessed.
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(2) The licensee will submit evidence staff has submitted to a live scan and have been association by 11/6/2020
Type B
11/09/2020
Section Cited

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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff

This requirement was not met as evidenced by:
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The Licensee did not provide resident or staff files during a complaint visit.
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #2
FACILITY NUMBER: 198603003
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2020
Section Cited

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87211(a)(1)(A) (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days ...
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(A) Death of any resident from any cause regardless of where the death occurred, including but not limited ...
This requirement was not met as evidence by: The facility had (5) deaths and none of them were reported
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The Licensee shall submit an LIC 624A for the (5) deaths not report to CCL by 11/9/2020

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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3