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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 07/27/2023
Date Signed: 07/27/2023 05:14:46 PM


Document Has Been Signed on 07/27/2023 05:14 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
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: 6DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Staff#1, lead staffTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with staff#1 who assisted with the visit. The facility is licensed to serve six (6) non-ambulatory residents who are ages 60 and above and approved for four (4) Hospice Waiver. Facility had dementia program on file. Currently, two (2) residents on hospice. LPA discussed the purpose of today's visit with staff#1 and also administrator, staff#2, over the phone.

During the visit, LPA conducted staff/resident interviews, used CARE inspection tool, and toured the facility.



The facility is a single story home located in a residential neighborhood, consisted of three (3) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a kitchen, a dining room, a living room with TV and a garage, and indoor/outdoor activity areas. Hot water temperature is measured at 119.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Smoke detectors and carbon monoxide detectors were operational.

Due to insufficient time and information during the visit at this time, this annual visit needs further investigation.



Exit conference was conducted and a copy of this report was provided to staff#2.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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