<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 05/28/2026
Date Signed: 06/12/2026 04:28:43 PM

Document Has Been Signed on 06/12/2026 04:28 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALTA LOMA GARDENS RESIDENTIAL CARE #2FACILITY NUMBER:
198603003
ADMINISTRATOR/
DIRECTOR:		STARK PLEITEZ, ANA MFACILITY TYPE:
740
ADDRESS:1667 WOODBEND DRTELEPHONE:
(818) 922-5427
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 4DATE:
05/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Eva Tancinco, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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
Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Eva Tancinco and explained the reason for the visit. Ana Stark Pleitez, Administrator arrived shortly thereafter.

The facility is licensed to serve residents ages sixty (60) and older. The approved capacity is six (6) non-ambulatory residents. The facility is approved to retain no more than four (4) residents receiving hospice care.

There was one (1) residents under hospice care during inspection.

Facility Tour & Observations

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. “Oxygen in Use / No Smoking” signs were not observed throughout the facility. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

The facility is located in a residential area and is a one-story home consisting of six (6) resident bedrooms and four (4) restrooms, including two private resident restrooms, one guest restroom, and one caregiver restroom. The facility also includes a living room, kitchen, dining area, garage with an extra washer and dryer, front yard, and backyard. The property includes caregiver corridors located within and near the garage area. LPA observed all six (6) resident bedrooms and verified that each contained the required furnishings, including a bed, mattress, linens, dresser, chair, and adequate lighting. Cleaning supplies and toxic substances were observed to be inaccessible to residents and stored in a locked kitchen cabinet beneath the sink and in a hallway closet. Bathrooms were observed to be clean and equipped with required grab bars near toilets and inside showers, as well as non-skid mats. During the visit, the hot water temperature measured above 140°F, which exceeds the required range of 105°F–120°F. A citation will be issued. Extra linens and towels were observed to be available in a hallway cabinet. (continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2026
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 9
Document Has Been Signed on 06/12/2026 04:28 PM - It Cannot Be Edited


Created By: Gabriela Castro On 05/28/2026 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 4 out of 4 bathrooms observed, hot water temperature measured 140°F and above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
1
2
3
4
Licensee shall immediately adjust the hot water temperature to ensure it remains within the required range of 105°F–120°F in all resident bathrooms. Licensee shall also submit a written plan describing how ongoing monitoring of water temperatures will be conducted to ensure continued compliance by POC due date.
Licensee shall monitor and document water temperature readings daily for one (1) week and submit the temperature log to LPA by 06/05/2026.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the refrigerator in the kitchen had medication that was not locked and made accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
1
2
3
4
Licensee shall ensure all refrigerated medications are stored in a locked container or locked refrigerator inaccessible to residents in care. Licensee shall submit proof of correction to LPA by the POC due date, including photographs showing refrigerated medications secured in a locked storage area.
***LPA observed correction during visit. Medication was placed in refrigerator located in the garage. Inaccessible to residents.***
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2026


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 06/12/2026 04:28 PM - It Cannot Be Edited


Created By: Gabriela Castro On 05/28/2026 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 4 resident files reviewed, as residents R1 and R3 did not have physician orders for the use of bed rails maintained in their files. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
1
2
3
4
Licensee shall obtain physician orders for the use of bed rails for residents R1 and R3 and maintain the documentation in each resident’s file. Licensee shall submit copies of the physician orders to LPA by the POC due date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as oxygenuse was observed. Required oxygen warning signs were not posted in the facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
1
2
3
4
Licensee shall post required oxygen warning signs in all applicable oxygen-use areas within the facility. Licensee shall submit proof of correction to LPA by the POC due date, including photographs showing the oxygen warning signs posted.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #2
FACILITY NUMBER: 198603003
VISIT DATE: 05/28/2026
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
Smoke and carbon monoxide detectors were tested, found to be functional, and observed to be interconnected throughout the facility. Fire extinguishers were observed to be readily available throughout the facility. No bodies of water were present on the premises. The backyard contained shaded seating areas, as well as additional washers, dryers, and refrigerators. Passageways and exits were observed to be clear and unobstructed.

Food Service

Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees °F and freezer 0-degree °C) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives and were observed in a locked kitchen cabinet.

Health-Related Services & Records

Four (4) resident files were reviewed and found to contain current required documents, including Admission Agreements, Pre-Placement Appraisals, Consents, Needs and Services Plans, Physician’s Reports, ambulatory status documentation, and Rights Acknowledgments.

During record review, LPA observed deficiencies in resident records. Residents R1–R3 were missing updated annual Needs and Services Plans. Additionally, residents R1 and R3 did not have physician orders for the use of bed rails maintained in their files. Deficiencies will be cited.

Disaster Preparedness

Last fire/earthquake drill was conducted on April 3, 2026, with logs available. LIC 610D Emergency Disaster Plan was posted on front entry bulletin board. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. Infection Control Plan was updated.

Personnel Records & Training

Four (4) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Ana Pleitez was valid through May 25, 2027.

Insurance

Liability insurance was in compliance.

An exit interview was conducted with Eva Tancinco, Caregiver. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 06/12/2026 04:28 PM - It Cannot Be Edited


Created By: Gabriela Castro On 05/28/2026 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 4 resident files reviewed, as residents R1–R3 did not have updated annual re-appraisals maintained in their files. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
1
2
3
4
Licensee shall complete updated annual re-appraisals for residents R1–R3 and maintain the documents in each resident’s file. Licensee shall submit copies of the completed re-appraisals to LPA by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2026


LIC809 (FAS) - (06/04)
Page: 9 of 9