198603003-8-16-2022-28-AS-MVAO-CJFSZ9-20220920141845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603003
Report Date: 08/16/2022
Date Signed: 08/16/2022 01:48:23 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
08/11/2022 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220811100333

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:	12:00 PM
MET WITH:	Facility Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff gave resident incorrect amount of medication.
Resident sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10 day complaint visit to investigate the above allegations. LPA met with Facility Administrator and discussed the purpose of today's visit.

During today's visit, LPA obtained a copy of the staff roster and resident roster. LPA reviewed R-2's file and obtained relevant documentation. LPA also interviewed the Facility Administrator, Resident #1 through Resident #3 (R-1 through R-3).

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-20220811100333

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: Facility staff gave resident incorrect amount of medication. Per Administrator interview, R-2 was admitted to this facility on 08/04/22 in the evening. Per Administrator, upon R-2’s arrival, Administrator noticed (2) bottles of Quantiapine Fumarate (both written on 07/20/22) (1) bottle indicated 50mg “take 1 tablet by mouth twice a day” and the other bottle indicated 100mg “take 1 tablet by mouth once daily”. Per Administrator, a request for clarification on Quantiapine Fumarate dosage was sent to R-2’s Physician prior to administering this medication on the same day of admission. Per documentation reviewed, R-2’s Physician clarified the order on 08/05/22 (as R-2 was admitted the evening on 08/04/22) for Quantiapine Fumarate to be administered 50mg twice per day. Per interview, R-2 was not given the incorrect amount of medication. Interview and collected documentation does not corroborate this allegation.

Allegation: Resident sustained unexplained bruising while in care. Per Administrator interview, R-2 was admitted to this facility on 08/04/22 in the evening. Per Administrator, upon R-2’s arrival, Administrator noticed R-2 of having bruising on the arms due to a fall that R-2 sustained while residing at home. Per Administrator, the bruising was not reported as Administrator was informed that R-2 had fallen at home and sustained bruising. Administrator also provided a copy of hospital discharge orders with education information on “fall prevention in the home, adult” that was provided to R-2 upon discharge from the hospital. Interview conducted and documentation reviewed does not corroborate this allegation.

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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