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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 05/04/2021
Date Signed: 05/04/2021 03:41:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALTA LOMA GARDENS RESIDENTIAL CARE #1FACILITY NUMBER:
361880570
ADMINISTRATOR:STARK PLEITEZ, ANAFACILITY TYPE:
740
ADDRESS:6896 HELLMAN AVETELEPHONE:
(818) 922-5427
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: 5DATE:
05/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Oliver "OJ" Velasco - CaregiverTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin observed deficiencies while investigating complaint control # 18-AS-20210430090536. LPA Colvin observed that staff members on duty during today's visit (S1 & S2) were not associated to the facility. LPA Colvin additionally observed that S1 does not have a current criminal record clearance and needs an exemption to be approved prior to being cleared to work in the facility. S2 started three months ago and S1 has been working at the facility for over 2 years, but had her criminal record clearance revoked in 2019. LPA Colvin additionally observed that the facility was cited for S1's lack of current criminal record clearance back on 10/22/19. A deficiency is being cited for both staff and civil penalties are being assessed for $500 each ($100 per day x 5 days).

Additionally, LPA Colvin has been requesting records from the Administrator for another complaint investigation (#18-AS-20200819151426) since 8/28/20, and has followed up with re-requesting documents three times (9/4/20, 9/16/20, and 9/25/20). LPA Colvin is citing a deficiency for failure to provide records to Licensing staff. During today's visit, LPA Colvin was unable to access staff and resident records (including Hospice), as the Administrator keeps the files off-site and LPA Colvin was unable to reach the Administrator. LPA Colvin contacted the Administrator via call and text and additionally had the staff attempt to contact her as well. Deficiency cited.

Due to the serious deficiencies cited today as well as the numerous complaints that have been reported regarding this facility, LPA Colvin is scheduling an Informal Meeting (via telephone) with the Licensee/Administrator for Thursday, 5/6/21 at 9:00am. LPA Colvin was unable to get a hold of Licensee/Administrator "Margarita" Ana Stark during today's visit, so LPA Colvin will be sending a notice of the Informal Meeting via email to the Licensee/Administrator as well.

An exit interview was conducted and a copy of this report, LIC809D, all civil penalty forms and appeal rights, along with LIC 811 was provided to to facility representative (caregiver) Oliver "OJ" Velasco.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2021
Section Cited

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Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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This requirement was not met by: Based on record review and observation, the Licensee did not comply with the above requirement with at least one staff. LPA Colvin observed that S2 did not have their criminal record clearanced transferred to the facility. This is an immediate safety risk for all residents.
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Type A
05/05/2021
Section Cited

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Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department
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This requirement was not met by: Based on record review and observation, the Licensee did not comply with this requirement with at least one staff. LPA Colvin observed that S1 does not have a valid criminal record clearance and requires an exemption. This is an immediate safety risk to residents.
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schedule by Plan of Correction date of 5/5/21.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2021
Section Cited

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Resident Records: (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying... This requirement is not met as evidenced by:
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Based on observations and interviews, the Licensee failed to submit/provide resident records for inspection by Licensing Agency on at least three occasions (9/4/20, 9/16/20, and 9/25/20). This is an immediate health risk & personal rights risk to all residents due to impeding Licensing's investigations.
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Type A
05/05/2021
Section Cited

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Personnel Records: (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by:
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Based on observations and interviews, the Licensee failed to previously submit/provide resident records for inspection by Licensing Agency, and records were unavailable during today's visit. This is an immediate health risk & personal rights risk to all residents due to impeding Licensing's investigations.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3