198603003-8-16-2022-28-AS-MVAO-CJ8RFY-20220913125956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603003
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:32:10 PM

Unsubstantiated

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
12/10/2021 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211210130007

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: 3	DATE:	08/16/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Facility Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Administrator worked while infected with COVID 19.
Staff did not report COVID 19 positive.
Staff are not feeding the resident properly.
Staff are not assisting resident with managed incontinence.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit on 12/16/21.
During this initial visit, LPA interviewed Staff #1 (S-1), Staff #2 (S-2), Resident #3 (R-3) and attempted to interview (Resident #4). LPA was unable to interview Resident #1 (R-1) nor Resident #2 (R-2) as both R-1 and R-2 were asleep at the time of this visit. LPA also reviewed the hospice file, facility staff notes file and Medication Administration Records (MARs) for R-1.

During today's visit, LPA interviewed Resident #4 and Resident #5 (R-4 and R-5) and Facility Administator LPA also reviewed R-1's log for R-1's feeding and incontinence care and obtained copies of revelevant documentation. R-1 and R-2 were not interviewed as R-1 and R-2 are now deceased.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211210130007

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: 08/16/2022

NARRATIVE

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Allegation: Administrator worked while infected with COVID 19. Staff interviews revealed that the Facility Administrator has not been infected with COVID 19. Per Administrator, Administrator has not been diagnosed with COVID 19. Administrator indicated Administrator left out of town on 12/05/2021 and prior to departure and return, COVID 19 testing was required. Administrator indicated there were a total of (3) COVID 19 tests administered (first) was administered (1) week prior to the departure, (second) was administered on 12/05/2021 and the (third) was administered on 12/09/22 (upon return) which all tested negative for COVID-19. Administrator also provided proof of receiving both COVID 19 vaccines (01/29/21 and 02/19/21) and booster (10/14/21). Interviewed Residents were unable to answer this question as they are diagnosed with Dementia. Staff interviews do not corroborate this allegation.

Allegation: Staff did not report COVID 19 positive. Staff interviews revealed that the Facility Administrator, staff nor Residents have not been infected with COVID 19. Administrator indicated all staff continued to work with Residents as they were not COVID 19 positive. Interviewed Residents were unable to answer this question as they are diagnosed with Dementia. Staff interviews do not corroborate this allegation.

Allegation: Staff are not feeding the resident properly. Staff interviews revealed that R-1 was a slow eater. Staff interviews indicated R-1 was not on a special diet and will take approximately 2 to 3 hours to finish R-1's meal. Staff interviews also revealed that staff maintained a log documenting R-1's meal consumption. Per staff interviews, all residents have a daily log for meal consumption. Resident interviews indicated staff provide adequate meals and that residents are fed properly. Staff interviews, Resident interviews and obtained documentation do not corroborate this allegation.

Allegation: Staff are not assisting resident with managed incontinence. Staff interviews indicated staff assisted R-1 with R-1's incontinence care. Per staff interviews, staff maintained an incontinence log for R-1. Per Staff interviews, R-1's incontinence care was monitored by staff closely as R-1 always would request a change as R-1 felt her adult diaper to be wet. Per staff interviews, staff would change R-1 even if R-1's diaper was dry. Per staff interviews, all residents have a daily log for incontinence care. Resident interviews revealed that their incontinence care is taken care of by staff in a timely manner.

Refer to LIC 9099C for the continuation of this report.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211210130007

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: 08/16/2022

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	Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, copy of appeal rights and a copy of this report was provided to the Facility Administrator.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

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