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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880570
Report Date: 06/23/2023
Date Signed: 06/23/2023 12:29:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200819151426
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: 6DATE:
06/23/2023
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Administrator, Ana StarkTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff failed to destroy previous residents’ centrally stored prescription medications.
Staff left resident in soiled clothing for extended amount of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate and deliver findings on the above allegations. LPA met with administratopr, Ana Stark who was informed of the purpose of the visit. LPA conducted interviews, documented observations, and conducted records reviews.

Regarding “Staff failed to destroy previous residents’ centrally stored prescription medications.” LPA reviewed where the facility stores the centrally stored medications. During the facility tour it was found that prior resident, R1’s medication was being kept in the facility garage. It was found through interview that the resident had moved out one (1) year prior. (continued on 9099-C page)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
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 18-AS-20200819151426
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570
VISIT DATE: 06/23/2023
NARRATIVE
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 The administrator stated they had forgotten to destroy the medication. LPA requested destruction records for previous residents and found that that R2 had a documented destruction record for medications. During the time of the visit, the administrator destroyed R1’s medication and documented this. Due to medication being found during the time of today’s visit that the administrator failed to destroy, the allegation is substantiated.

Regarding “Staff left resident in soiled clothing for extended amount of time.”, it was alleged that overnight staff at the facility were not changing resident and as a result were left soiled overnight. LPA interviewed night staff at the time of the visit who stated that residents were changed every 2 hours, including overnight. They stated R3 was the only incontinent resident at this time of the interview, June 23, 2023. LPA reviewed the incontinence accountability log for R3 and found that on several occasions the resident was not documented as changed after 5pm, with next time changed as 5am. Therefore the allegation is substantiated.

A finding of substantiated means the preponderance of the evidence standard has been met. Substantiated finding was cited under Title 22 Division 6 Chapter 8. Plan of correction was made with the administrator.

An exit interview was conducted with administrator, Ana Stark where this report, LIC9099-D and appeal rights were reviewed and provided to them.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200819151426

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: 6DATE:
06/23/2023
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Administrator, Ana StarkTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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2
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9
Staff failed to provide adequate food service to residents.
Staff used resident's personal care products on other residents.
Staff failed to protect resident from sustaining injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate and deliver findings on the above allegations. LPA met with administrator, Ana Stark who was informed of the purpose of the visit. LPA conducted interviews, documented observations, and conducted records reviews.

Regarding “Staff failed to provide adequate food service to residents.”, it was alleged that the facility was not provide the resident with a balanced meal everyday. It was alleged resident only received meat (3) times a a week. LPA requested facility menus for August 2020 and was provided with staff progress noted for R4 from August 2020 where it was written what food residents ate that day. LPA found that protein was provided to the residents during meals. (continued on LIC9099-c page)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
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 18-AS-20200819151426
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570
VISIT DATE: 06/23/2023
NARRATIVE
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LPA interviewed the administrator and (1) staff present during today’s visit, who stated that a protein is served to the resident every day. LPA observed during the visit that resident were fed protein for lunch. Therefore, the allegation is unsubstantiated.

Regarding “Staff used resident's personal care products on other residents”, it was alleged that staff used private pay residents supplies when the facility ran out. LPA interviewed staff and administrator during the time of the visit who stated that all current residents provide their own supplies. The administrator stated they have a subscription service with Amazon since the facility opened, and receive incontinent supplies on a monthly basis. LPA observed the facility’s incontinent supplies and found that there were enough supplies to be used in case resident ran out of their supplies. LPA also observed (3) resident rooms for incontinent supplies and found that had extra supplies in their room, including supplies that the administrator had supplied them. Therefore the allegation is unsubstantiated.

Regarding “Staff failed to protect resident from sustaining injury.” It was alleged that R4 had gone to the liquor store and bought liquor, had become intoxicated at the facility, which resulted in a fall and stitched to R4 forehead. LPA interviewed administrator who stated that the resident only went on supervised outings to the store, with them and staff 1 (S1). They stated that R4 did not purchase alcohol during their time at the facility. R4 is unable to be interviewed as they are now deceased. LPA interviewed S1 during the time of the visit who stated that R2 did sustain a fall where the resident had to have stitched to their forehead, but that this fall had occurred at night when the resident got up to go to the bathroom. LPA could not find any evidence to corroborate the allegation. Therefore, the allegation is also unsubstantiated.

A finding of unsubstantiated means that although the allegation is valid, the preponderance of the evidence standard has not been met.

An exit interview was conducted where this report was reviewed and provided to Administrator, Ana Stark.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200819151426
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2023
Section Cited
CCR
87456(i)
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(i) Prescription medications...which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record,
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The administrator disposed of the medication immediately during the visit. The administrator agreed to send a certified statement on new prcodure for destructing medication.
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to be retained for at least three years...This requirment was not met as evidenced by: R1's medication which had not been disposed of and kept in the facility garage during the time of the visit.
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Type B
06/27/2023
Section Cited
CCR
87625(b)(2)
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(b) In addition... the licensee shall be responsible for the following:(2) Ensuring that incontinent residents are checked...including during the night.This requirment was not met as evidenced by:
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The licensee agreed to retrain staff on incontinent care by the POC due date.
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 Based on records review and intervie wit was round that R3 was not being changed after 5pm, and changed again until 5am. This is a potential health, saftey or personal rights risk to residents in care.
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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: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5