361880570-11-8-2023-18-AS-KCLS-CXKNYV-20231114095315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880570
Report Date: 10/28/2023
Date Signed: 11/08/2023 10:55:28 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2021 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 18-AS-20210430090536

FACILITY NAME:	ALTA LOMA GARDENS RESIDENTIAL CARE #1		FACILITY NUMBER:	361880570
ADMINISTRATOR:	STARK PLEITEZ, ANA		FACILITY TYPE:	740
ADDRESS:	6896 HELLMAN AVE		TELEPHONE:	(818) 922-5427
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91701
CAPACITY:	6	CENSUS: 5	DATE:	10/28/2023
		UNANNOUNCED	TIME BEGAN:	02:34 PM
MET WITH:	Lavonne Brinley Support Staff		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Residents sustained pressure injuries while in care.
Staff are not assisting residents with ADLs.
Administrator is not fulfilling management duties.
Facility does not have sufficient staffing.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to deliver the findings for the allegations listed above. LPA met with Lavonne Brinley Support Staff who left during the visit and gave her care staff Lavonne Brinley.
The investigation consisted of interviews with the administrator, two (2) staff members, four (4) residents and review of five (5) residents files.
LPA interviewed two staff members who stated there was only one resident at the facility in the past who was diagnosed with a pressure injury but was being treated by hospice three times a week. LPA also observed documentation that confirms there was one resident with a pressure injury and was being treated by hospice. The interviews with the staff were asked if staffing was sufficient, and they stated they would like to have additional staff at night, but they manage with who they have. LPA also reviewed staff schedule that reflect there is sufficient staff for night shift. The interviews with the four (4) residents stated that their (ADL’s) activities of daily living were being met daily by staff members. The interviews with staff and administrator all stated the administrator is at the facility daily. During the visit LPA observed that there was sufficient staff, residents ADL’s appeared to be met and the administrator was at the facility upon arrival.
Based on interviews, documentation, and observations the allegations are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided with appeal rights to Lavonne Brinley Support Staff at the conclusion of the visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

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 18-AS-20210430090536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1	FACILITY NUMBER: 361880570
	VISIT DATE: 10/28/2023

NARRATIVE

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LPA was unable to interview resident 1(R1) because they are deceased. LPA observed the facility files for Resident 1(R1) and their file did confirm that they were being treated by a hospice Agency off and on from 2019 through 2023.

Based on the interviews and file review the above finding is Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and provided to Lavonne Brinley at the conclusion of the visit with appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

LIC9099 (FAS) - (06/04)

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