198603003-7-9-2021-28-AS-MVAO-C75MZ8-20210923100244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603003
Report Date: 07/09/2021
Date Signed: 07/09/2021 03:55:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2021 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20210122103341

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
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Caregiver, Gerardo Alfonso		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff left resident in soiled clothing for an extended period of time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez and Linda Almaraz made a subsenquent unannounced visit to conduct a complaint investigation for the allegation listed above. LPA's met with Caregiver, Gerardo Alfonso and explained the reason for the visit.

The investigation consisted of the following: On 01/29/2021, LPA Almaraz conducted interviews with Administrator and Staff #1. LPA also requested the following documentation to be sent via email or fax by 1/29/2021, staff and resident roster and files for Residents #1-3. On 07/09/2021, LPA Lopez conducted interviews with resident #1 and visitor of resident #2 and attempted to interview resident #2 but resident was non-verbal. LPA Almaraz interviewed resident #3 and Staff #2 and #3.
(Continued on a LIC-9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210122103341

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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The investigation revealed the following: Based on statements and interviews conducted with staff all residents are changed frequently and are check on every 2-3 hours. One (1) out of (3) resident interviews reveled they are not changed often. Based on interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

An exit interview was conducted with Gerardo Alfonso and copy of this report was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
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

LIC9099 (FAS) - (06/04)

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