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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603003
Report Date: 07/13/2022
Date Signed: 07/13/2022 12:25:43 PM


Document Has Been Signed on 07/13/2022 12:25 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
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:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Margarita StarkTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Staff #1 (S1) and explained the reason for the visit. Administrator, Margarita Stark was called and arrived a short time later. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications and records, staff records and observed the food supply. The facility cares for elderly residents and is approved to care for 4 hospice residents. There are currently 2 residents on hospice.

All resident bedrooms were toured. Bedrooms have the required bed, bedframe, linen, dresser, light, and closet space. Resident bathrooms were toured and the hot water was 116.4 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. There is a second refrigerator in the outside patio. The common areas include the living room and dining area. These areas are clean and have the required furniture. Facility currently has at least a 30-day supply of PPEs. There are cameras inside the facility in common areas only. There is a screening station with PPEs at the entrance of the facility. Staff document resident temperatures and symptoms daily.

Resident files were reviewed. Resident #1 (R1) and Resident (R2) did not have a pre-admission appraisal on file. R1 also did not have an admission agreement on file. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. S1 and Staff #2 (S2) did not have health screenings on file. All residents' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiencies observed during the visit are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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 3


Document Has Been Signed on 07/13/2022 12:25 PM - It Cannot Be Edited

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: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 2 staff files which poses a potential health, safety or personal rights risk to persons in care.
S1 and S2 did not have a health screening on file.
POC Due Date: 07/27/2022
Plan of Correction
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Administrator agreed to submit proof of health screenings by 7/27/22.

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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/13/2022 12:25 PM - It Cannot Be Edited

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: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 resident records which poses a potential health, safety or personal rights risk to persons in care.
Resident #1 (R1) and Resident (R2) did not have a pre-admission appraisal on file. R1 also did not have an admission agreement on file.
POC Due Date: 07/27/2022
Plan of Correction
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4
Administrator agreed to submit documents by 7/27/22.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3