198603003-11-4-2020-28-AS-MVAO-BXPN9H-20210128091559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603003
Report Date: 10/26/2020
Date Signed: 11/04/2020 07:23:33 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2020 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200915094446

FACILITY NAME:	ALTA LOMA GARDENS RESIDENTIAL CARE #2		FACILITY NUMBER:	198603003
ADMINISTRATOR:	STARK PLEITEZ, ANA M		FACILITY TYPE:	740
ADDRESS:	1667 WOODBEND DR		TELEPHONE:	(818) 922-5427
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 4	DATE:	10/26/2020
		UNANNOUNCED	TIME BEGAN:	11:21 AM
MET WITH:	Caregiver, Patty Moreno		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not properly trained.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Patty Moreno, Caregiver.

The initial complaint investigation was conducted telephonically on 9/24/20. During the initial investigation, telephone interview was conducted with the administrator and a virtual tour of the facility was conducted. LPA obtained a copy of the resident and staff roster. After the initial visit, interviews were conducted with staff and resident's family members. On 10/12/20, a subsequent tele-visit was conducted to interview residents. All four residents in care were interviewed. Administrator was asked to provide proof of staff training.

Continued on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20200915094446

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/26/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following: It was discovered that Resident #1 (R1) has a colostomy bag. Administrator was asked to provide proof of staff training which LPA never obtained. Interviews conducted with caregivers revealed that caregivers have been caring for R1’s colostomy bag such as changing the bag. However, caregivers reported that they have not been trained at this facility by a skilled medical professional as required by Title 22 Regulations. Also, none of the caregivers are skilled medical professionals such as Registered Nurse (RN) or Licensed Vocational Nurse (LVN).

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, citations are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Patty Moreno and a hard copy was provided via email to administrator for signature along with appeal rights.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20200915094446

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/26/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/06/2020 Section Cited CCR 87621(b)(1)(A-B)	1 2 3 4 5 6 7	Colostomy/Ileostomy:(b) In addition to Section 87611(b), the licensees shall be responsible for the following: (1) Ensuring that ostomy care is provided by an appropriately skilled professional. (A) The ostomy bag and adhesive may be changed by facility staff who have been instructed by the professional.(B) There shall be written documentation.........	1 2 3 4 5 6 7	Administrator will ensure all current staff providing care to R1 are properly trained per regulations. Proof of training will be submitted by POC due date.
	8 9 10 11 12 13 14	This deficiency was evidenced by the following: It was confirmed R1 has a colostomy bag and staff confirmed they care for the colostomy. There is no proof of appropriate training for staff by a skilled medical professional.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2020 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200915094446

FACILITY NAME:	ALTA LOMA GARDENS RESIDENTIAL CARE #2		FACILITY NUMBER:	198603003
ADMINISTRATOR:	STARK PLEITEZ, ANA M		FACILITY TYPE:	740
ADDRESS:	1667 WOODBEND DR		TELEPHONE:	(818) 922-5427
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 4	DATE:	10/26/2020
		UNANNOUNCED	TIME BEGAN:	11:21 AM
MET WITH:	Caregiver, Patty Moreno		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff confiscated resident's personal property.
Resident did not have access to the bathroom.
Staff are also responsible for supervising children in the facility causing a lack of supervision for residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20200915094446

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/26/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following: Allegation: Staff confiscated resident's personal property.
It’s alleged staff confiscated Resident #2’s (R2) cellphone. Staff interviewed denied the allegation. R2’s conservator was interviewed and indicated that he/she asked administrator to take R2’s cellphone for a day due to R2’s family spreading misinformation about another family member and the family member’s possible death. The conservator setup transportation for R2 to see the family member prior to hearing about the misinformation from other family members. The conservator stated he/she was protecting R2 from news that would upset R2 and possibly affect R2’s health. R2 was interviewed twice and R2 did not have evidence to support the allegation.

Allegation: Resident did not have access to the bathroom. Staff interviewed denied the allegation. Staff indicated that there was 1 bathroom out of order for a day or two because it was clogged. Residents were asked to use another bathroom or a commode. Residents that could answer the question deny the allegation. Other residents could not answer the question due to cognitive impairment. Family members interviewed did not have any information regarding this allegation.

Allegation: Staff are also responsible for supervising children in the facility causing a lack of supervision for residents. It’s alleged that administrator has left her children at the facility for caregivers to take care of as she is away from the facility. Caregivers interviewed denied the allegation and reported that administrator has never left the children there for caregivers to take care of while they are caring for residents. Administrator indicated she has paid a staff member to pick up her children, but the staff member was not working as a caregiver at that time. One caregiver indicated he/she has picked up the administrator’s children but was not working as a caregiver at the time. Residents indicated administrator has never left the children in the facility for caregivers to take care of. Family members interviewed did not have any concerns regarding the children.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 5