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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603003
Report Date: 09/07/2021
Date Signed: 09/07/2021 04:11:36 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
10/27/2020 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20201027111705
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: 3DATE:
09/07/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Margarita StarkTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff mismanaged resident’s medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) Linda Almaraz and Alberto Lopez conducted a sub-sequent complaint visit to investigate the allegation listed above. LPA's were greeted by Caregiver, Oliver Velasco and explained the reason for today's visit. Later during the visit, Licensee, Margarita Stark arrived at the facility.

The investigation consisted of the following: On 11/3/2020, LPA Almaraz conducted interviews with Licensee, Staff #1, Residents #1-3 and attempted to interview Resident #4 but was unable (Resident was asleep). LPA Almaraz requested copies of: Staff and Resident Roster, Files for Residents #1-4 at about 1:35PM. LPA also requested files for all staff and former Residents #5-9, who have passed away. The only documents received were staff and resident rosters. LPA Almaraz was unable to review files because they were never sent. On 6/4/21 and 9/7/21, LPA's reviewed the medication for all residents, including new residents who shall be referred to as residents #10 and #11.

The investigation revealed the following: (Continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20201027111705
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: 09/07/2021
NARRATIVE
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While reviewing medications for current residents at the facility, residents #1, 10 and 11, LPA's discovered no Medication Administration Record (MAR) logs for the month of September 2021 were available. Per Licensee, she had not created the logs but was still dispensing medications to all residents. Upon reviewing their logs for August, LPA's notice a patterned of medication not being dispensed on certain days, in particular Tuesday's and Saturday's. No medication was dispensed on August 14th, 17th, 21st, 24th, 28th, and the 31st according to August's MAR log. Resident #1 was missing medication (LATANOPROST 0.005%) eye drops. Resident #1 had a multi-vitamin and Stool softener (DOCUSATE SODIUM 100mg) in the residents medication with out a physicians order. Per Licensee, they have been giving both to the resident without the order. Resident #10 had several discrepancies of the following medication (LISNOPRIL 40MG, SIMVASTATIN 20MG, NIFEDIPINE 30MG, FUROSEMIDE 20MG, FINASTERIDE 5MG, and CLOPIDOGREL 75MG), all these medications had excessive amount of pills left indicating it was not given as directed. Resident #11 was not given their medication (MELATONIN 3MG) as directed by physicians order. Per August MAR log, the resident was not given the melatonin everyday and the facility had a duplicate prescription that appeared was given to the resident twice a day instead of once a day.

Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

Deficiencies cited under California Code of Regulations Title 22. Please see LIC 9099D


An exit interview was conducted with Margarita Stark and copy of this report was provided. Appeal Rights provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/27/2020 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20201027111705

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: 3DATE:
09/07/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Margarita StarkTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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9
Staff failed to help resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) Linda Almaraz and Alberto Lopez conducted a sub-sequent complaint visit to investigate the allegation listed above. LPA's was greeted by Caregiver, Oliver Velasco and explained the reason for today's visit. Later during the visit, Licensee, Margarita Stark arrived at the facility.

The investigation consisted of the following: On 11/3/2020, LPA Almaraz conducted interviews with Licensee, Staff #1, Residents #1-3 and attempted to interview Resident #4 but was unable (Resident was asleep). LPA Almaraz requested copies of: Staff and Resident Roster, Files for Residents #1-4 at about 1:35PM. LPA also requested files for all staff and former Residents #5-9, who have passed away. The only documents received were staff and resident rosters. LPA Almaraz was unable to review files because they were never sent. On 6/4/21 and 9/7/21, LPA's reviewed the medication for all residents.

The investigation revealed the following: (Continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20201027111705
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: 09/07/2021
NARRATIVE
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All resident interviewed stated they are changed in a timely manner and have no issues with the time it takes for the staff to change them. Interviews with staff also indicated there is no staffing issues and residents are changed promptly. Per interviews with staff, residents are checked on every 2 hours.

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 is 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 Margarita Stark and copy of this report was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20201027111705
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2021
Section Cited
CCR
87465(h)(6)
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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A)-(F)
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Licensee will ensure all medication and vitamins given to residents have an order in place prior to dispencing the medication and that it is logged when given.

Licensee will read CCR 87465 and will send a signed written statement stating she has read and understands the full section and will
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This requirement was not met as evidence by:
The licensee was giving resident #1 a multi-vitamin and Stool softener (DOCUSATE SODIUM 100mg) with out a physcians order.
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to LPA by POC due sate
Type B
09/13/2021
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, ......provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
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Licensee will have a pharmacy conduct training with all staff who administer medication and herself.

Licensee will send material of subjects covered and sign in sheet of attendees by POC due date.
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This requirement was not met as evidence by:

Licensee failed to give resident #1, 10 and 11 their medication as prescribed by their physcians orders.
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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: 09/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5