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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:12:57 PM


Document Has Been Signed on 03/19/2024 03:12 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
GREATER LA AC/SC, 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: 5DATE:
03/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:John Robles Jr- CaregiverTIME COMPLETED:
03:27 PM
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Licensing Program Analyst (LPA) Mora conducted an unannounced plan of correction (POC) visit to follow up on deficiencies noted on 03/07/2024. LPA met with John Robles Jr (Caregiver) and explained the reason for the visit.

On 03/07/2024, LPA Mora conducted a subsequent complaint visit and the following was cited:

1. Title 22 Section Code 87204(a) - Facility was over capacity due to having a 7th resident. The facility has 5 residents. Administrator submitted a statement that they will comply with this regulation on 03/08/2024.

2. Title 22 Section Code 87307(a)(2)(B) - There was a resident residing in a room licensed as "Office". The room is now being used as intended. Administrator submitted a statement that they will comply with this regulation on 03/08/2024.

3. Title 22 Section Code 87208(a)(7)(A) - The garage was being used as a sleeping area for staff and there was no permits allowing this. Also, the garage was not licensed as a living/sleeping area for staff. During today's visit, LPA observed that the bed sheets on the bed in the garage have been removed and the bed will be stored in the garage, but be used for sleeping. The Administrator also submitted a statement that the garage will be used as intended and no one will sleep in the garage on 03/08/2024.

4. Title 22 Section Code 87307(d)(4) - There was a step down when opening a door in the kitchen area leading to a hallway that leads to the garage. This step down is not noticeable and can be a tripping hazard. This door was unlocked when LPA visited the facility. During today's visit, LPA observed that this area is now inaccessible to the residents due to Administrator installing an auto lock on the door.



5. Title 22 Section Code 87705(j) - All exit doors did not have an auditory device. During today's visit, LPA observed that all exit doors have an auditory device and were operable.

Exit interview was conducted with John Robles Jr (Caregiver) and a copy of this report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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