198603003-2-13-2024-28-AS-TVAO-D2UP2F-20240227095549

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603003
Report Date: 02/13/2024
Date Signed: 02/13/2024 12:51:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
02/12/2024 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240212095842

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: 6	DATE:	02/13/2024
		UNANNOUNCED	TIME BEGAN:	08:44 AM
MET WITH:	Caregiver Bobbie Robertson		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff does not provide residents with nutritious meals.
Facility does not post menu.
Staff does not prevent resident from posing a hazard to other residents.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 02/13/24 regarding the above allegations. LPA Ramirez was met by Caregiver Bobbie Robertson and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident Roster (LIC 9020), Staff#1 - 2 interviews(S1 – S2), Resident#3-5 interviews (R3 – R5 ), Attempted interview of Resident#1, 2, 6 (R1, R2, R6) Resident# 1-6 (R1- R6) record review, copy of Alta Loma Gardens Residential Care#2 General Facility Information and House Rules, copy of facility sample menu, copies of Resident# 1-6 (R1-R6): Physician Report, Daily Notes from 02/06/2024 through 02/12/2024, and physical plant tour.

See 9099-C for continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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 3

Control Number 28-AS-20240212095842

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #2	FACILITY NUMBER: 198603003
	VISIT DATE: 02/13/2024

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. Regarding Allegation(s): Staff does not provide residents with nutritious meals- It is alleged staff do prepare nutritious meals, like fruits and vegetables. LPA Ramirez conducted physical tour at approximately 8:20 am. LPA Ramirez observed R4 and R5 seated at the dining room table, eating breakfast. LPA Ramirez observed a decent serving of diced potatoes, scrambled eggs, bacon, and a croissant on R5’s plate. LPA Ramirez viewed facility Daily Notes dated 02/06/2024 through 02/12/2024, for all six (6) residents that documents date, time, meal intake% and description of what eat resident consumed. LPA Ramirez observed a variety of meals documented and observed fruits and vegetables being documented on somedays. LPA Ramirez observed staff documented most meals were 80% to 100% consumed on most days for each resident. Two (2) out of two (2) staff interviewed denied this allegation. Three (3) out of six (6) residents interviewed denied this allegation. R1 was sleeping during tour and could not be interviewed. R2 and R6 are receiving hospice care and could not be interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility does not post menu- It is alleged the facility does not post a menu of meals to be served. LPA Ramirez observed facility sample menu during file review. Per Title 22, Division 6, Chapter 8, Article 10 Food Services, 87555 General Food Service Requirements (b)(6)- The following food service requirements shall apply: In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request. Two (2) out of two (2) staff interviewed denied this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

See 9099-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20240212095842

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #2	FACILITY NUMBER: 198603003
	VISIT DATE: 02/13/2024

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

Staff does not prevent resident from posing a hazard to other residents- It is alleged that staff allow delivery packages to pile up in facility hallway and resident is unable to open door. Two (2) out of two (2) staff interviewed denied this allegation. LPA Ramirez toured facility including each resident room. LPA Ramirez did not observe any hazards inside or outside the facility. LPA Ramirez observed R1 and R3 to have private rooms. LPA Ramirez was able to enter R3’s room and did not observe any hazards. LPA Ramirez did observe several large bags with various unknown packaged items, in front of R3’s closet area. LPA Ramirez observed sufficient space for R3 and for staff to provide care and supervision. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3