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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 06/04/2024
Date Signed: 06/04/2024 05:05:13 PM


Document Has Been Signed on 06/04/2024 05:05 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: 6DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Caregiver Bobbie Robertson TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required 1-year Visit on
06/04/2024. LPA was met by Caregiver Bobbie Robertson and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which six (6) may be non-ambulatory and has a hospice waiver approved for four (4). There are currently two (2) residents receiving hospice care at this facility. Video surveillance was observed in common areas.

LPA OBSERVATIONS: The facility is a single-story dwelling located on a residential street and consists of four (4) resident bedrooms, three (3) bathroom, kitchen, dining room, living room, attached garage, front yard, and backyard. LPA Ramirez observed auditory devices on entry of door to be operational, sliding door and exits.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located under kitchen sink, to be inaccessible to six (1) out of one (1) resident in care. Kitchen sink water temperature was measured at 116.5 degrees F. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Nearby thermostat was observed to read 71-degree F.

Linen Closet: Contained plenty linens, towels, and hygiene products.



SEE 809-C
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/04/2024
NARRATIVE
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Resident Rooms 1-4: LPA Ramirez inspected four (4) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens.

Bathrooms 1-3: Water temperature in all bathrooms were measured to be within 105- 120 degrees F.

Backyard: Was clean and well maintained. No hazards were observed. Plenty of shade and seating was observed.

Garage: PA Ramirez observed emergency water and extra PPE/linens, and toiletry items in this area. Access to garage was observed to be inaccessible to six (6) out of six (6) residents in care.

Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. Last fire drill was conducted on 03/24/24.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for two (2) staff. LPA Ramirez observed an expired Administrator’s certificate for Stark Pleitez, Ana with an expiration date of 05/25/2021. LPA Ramirez will issue Type B deficiency based on this observation. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the two (2) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the two (2) personnel records reviewed.

Resident Records: Five (5) out of the six (6) resident records were accessible to LPA Ramirez. R1 and R2 were observed to missing required annual medical assessment. LPA Ramirez will issue two (2) Type B deficiencies based on this record review and observation.

Liability Insurance & Infection Control Plan: Facility will send proof of liability insurance within 7 calendar days. Facility will infection control plan within 7 calendar days.



Exit interview was conducted. Three (3) deficiencies were cited during this inspection. A copy of this report, 809-D and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/04/2024 05:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(13)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & record review, Administrator certificate for Ana Stark Pleitez has been exipred since 2021, the licensee did not comply with the section cited above in 6 out of 6 residents, and/or staff and visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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Licensee will re-train staff on this regulation by 06/18/2024 and provide LPA Ramirez with current Administrator Certificate by 06/18/2024.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, R3 file was not located by staff during inspection, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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Licensee will re-train staff on this regulation and LPA Ramirez will return to inspect R3's resident record.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/04/2024 05:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R1 & R2 did not have annual medical assessments, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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Licensee will email LPA Ramirez R1 and R2 medical assessment by06/18/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4