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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 06/04/2021
Date Signed: 06/04/2021 06:00:14 PM

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: 4DATE:
06/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Robin Johnson, CaregiverTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Linda Almaraz initiated a Case management visit at facility. During a visit at the facility, LPA observed an individual by the name of William Verner walk into the facility with his own set of keys. LPA was told by Mr. Verner he was the owner of the property and was dropping off the Licensee's son at the facility. LPA then observed Mr. Verner walk through the side of the home and unlock the side door with a pair of keys and enter the home where the child was and stood there for a few minutes. About half hour later, Mr.Verner and the Licensee's child walked out changed with water clothes. LPA contacted the Licensee and inquired about the situation. The Licensee stated Mr. Verner picks up her son sometimes and will watch him till she returns when her Aunt is not available and the he also does repairs at the facility. Licensee states he is at the facility about once a week. Mr.Verner is not associated to the facility or has a criminal background clearance on file. LPA also observed Caregiver Lavonne Brinkly (DOH: 1/2020) present at the facility.


Deficiencies cited under California Code of Regulations, Title 22, Division 6 and Chapter 1, documented on LIC 809D. Civil Penalties were assessed.

Exit interview was conducted telephonically, Appeals right and a copy of this report was provided to Caregiver at the facility.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 198603003
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2021
Section Cited

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Personnel requirements:
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
Obtain a California clearance or a criminal record exemption as required by law or Department regulations
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This requirement was not met as evidenced by: The following individual was present at the facility supervising the Licensee's child. LPA was informed telephonically by Licensee he watches the child when she is not present. LPA witnessed William Verner come in through a side door, stay at the facility and change before leaving the facility. LPA also observed Caregiver Lavonne Brinkly DOH: 1/2020 present at the facility. Both individuals are not associated to the facility
as today.
Immediate Civil Penalties were assessed.
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(2) Licensee will ensure all staff, visitors or volunteers who will be present at the facility are fingerprinted and associated prior to being at the facility. Licensee submit to LPA records of fingerprints and clearance to by 6/11/21

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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2021
LIC809 (FAS) - (06/04)
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