198603003-7-14-2021-28-AS-LMAZ-C4S28N-20210709171036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 07/09/2021
Date Signed: 07/14/2021 08:45:22 AM

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 #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: 3	DATE:	07/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Gerardo Alfonso		TIME COMPLETED:	05:15 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 Analysts (LPAs) Linda Almaraz and Alberto Lopez conducted an annual required visit. LPA's met with Caregivers, Gerardo and Glenda Alfonso and explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. Facility has submitted a mitigation plan and is pending approval. The facility is a 4 bedrooms 3 bathroom home located in a residential neighborhood. Facility has a main entry point for screening. All 4 clients bedrooms were toured. Each bedroom occupied had required furniture. The food in the kitchen has sufficient supply of 2 days perishable and 7 days non-perishable. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The backyard has a shaded area and sitting area. Medications are centrally stored and locked. Upon arriving to the facility, LPA's were greeted by Caregiver, Gerardo who was not wearing a face mask. All bathrooms, toilets, hand washing and shower/bathtub were toured. During the bathrooms tour LPA's and staff observed the toilet and shower for bathrooms #1 and #2 were clogged a long with the hand washing double sinks in bathroom #1. LPA's were told by staff there was a leak on the bathroom floors. Bathrooms had several towels on the floor and water started leaking to the hallway and resident #1's room. The hot water temperature in bathroom #1 measured at 143.3 degrees F. Bathroom #2 measured at 143.8 degrees F and bathroom #3 was at 143.5 degrees F. This was not within the required range of 105-120 degrees F. Medication administration logs for residents were not updated for the medication given in the morning today. Some medication and Pro re nata (PRN) medication was missing for Resident #1 and #2. Residents emergency contact numbers and records were not available/updated. (Continued on LIC 9099-C)

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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
	VISIT DATE: 07/09/2021

NARRATIVE

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LPA's also observed debris in the backyard. There was several white window shutters, cords, paint spray cans and tools. Sharp large Gardening Scissors were found in the backyard accessible to residents. Cabinets with cleaning solutions was not locked in the hallway and under the sink.

Deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted with the Administrator and a hardcopy was provided. Appeal Rights was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: 07/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

This requirement is not met as evidenced by: LPA's and staff observed water temperature on all 3 bathrooms not within the required range of 105-120 degrees F. Bathroom #1 measured at 143.3, Bathroom #2 measured at 143.8 and Bathroom #3 measured at 143.5 degrees F.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2021
	Plan of Correction
1 2 3 4	(1) Licensee shall adjust the water temperature within the required range of 105-120 degrees F within 24 hours and will submit proof to LPA via email or fax by POC due date of 7/10/21. (2) Licensee will monitor the water reading in all bathrooms daily and will document the reading for 7 days. Licensee will send a copy of the log to LPA by 7/16/21.

Type A

Section Cited

CCR

87303(e)(6)

This requirement is not met as evidenced by: LPA's and Staff observed the bathrooms toilet and showers in bathroom #1 and #2 clogged and leaking water all over the floor on to the hallway and rooms.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 3 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2021
	Plan of Correction
1 2 3 4	Licensee stated she will contact a plumber to go out within 24hrs to asses the issue and fix any plumbing issues immediately. Licensee shall submit receipt/record of services made by the plumber by POC due date.

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 Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: 07/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(2)

This requirement is not met as evidenced by: LPA's and staff observed the bathroom floor in bathrooms #1 and #2 with a puddle of water and towels covering the water. There was a leak present that was reaching the hallway and residents room.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 3 bathrooms had a puddle of water on the floor from a leak in the bathrooms which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2021
	Plan of Correction
1 2 3 4	Licensee shall ensure all water puddles are cleaned and there is no slipping hazards in the bathroom, hallways or rooms. Licensee shall send photo proof via fax or email of all cleaned/dried areas by POC due date.

Type B

Section Cited

CCR

87309(a)(1)

This requirement is not met as evidenced by: The backyard has several debris and window shutters on the floor. There was also spray cans and tools left out.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to having debris out in the back yard along with cans and tools which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2021
	Plan of Correction
1 2 3 4	Facility shall ensure that all furniture and debris is discarded from the backyard. Submit picture proof of correction by POC due date.

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 Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: 07/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

This requirement is not met as evidenced by: The facility had a hallway cabinet unlocked where they had cleaning solutions, such as clorox and the cabinet under the sink was also unlocked which also conatined cleaning solutions.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not keeping the cleaning solutions locked which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2021
	Plan of Correction
1 2 3 4	Licensee shall ensure all cleaning solutions are locked and not accesible to residents in care. Licensee shall send proof to LPA by poc due date.

Type B

Section Cited

CCR

87506(b)(8)

This requirement is not met as evidenced by: Facility did not have emergency contact information for 2 out 3 residents in care.
	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 3 residnets which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2021
	Plan of Correction
1 2 3 4	Licensee shall update all emergency contact information for all residents and will maintain in the resdients file. Licensee shall submit resdients Emergency contact form to LPA by POC due date.

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 Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

Page: 6 of 6

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: 07/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87564(c)(2)

This requirement is not met as evidenced by: Resident #1 and Resident #2 had missing prescribed medication and PRN medication.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 3 residents medications which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2021
	Plan of Correction
1 2 3 4	Licensee shall obtain missing medication for both residents, make it accesible to caregivers on duty and shall submit proof of obtained medication by POC due date.

Type B

Section Cited

CCR

87465(d)(3)

This requirement is not met as evidenced by: Medication Administration logs were not completed for today 7/9/21. Caregivers on duty stated they did not log the medication or PRN medication given in the morning or afternoon because they were not told to.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 residents medication administration logs were not completed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2021
	Plan of Correction
1 2 3 4	Licensee shall train all staff on medication administration and provide LPA training material and a sign in sheet of staff who were trained by POC due date.

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 Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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