361880570-2-13-2024-56-AS-ACON-D2EQTD-20240213112657

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:27:10 AM

Document Has Been Signed on 02/13/2024 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ALTA LOMA GARDENS RESIDENTIAL CARE #1		FACILITY NUMBER:	361880570
ADMINISTRATOR:	STARK PLEITEZ, ANA		FACILITY TYPE:	740
ADDRESS:	6896 HELLMAN AVE		TELEPHONE:	(909) 244-9031
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91701
CAPACITY:	6	CENSUS:	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:			TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Alta Loma Gardens Residential Care #1, Residential Care Facility for the Elderly unannounced, to conduct the Annual Inspection. LPA met with Caregiver, Alvin John, Espino; introduced self and stated purpose of the visit. LPA was invited inside facility and provided space to work. Mr. Espino informed LPA the Administrator was not available at the time of the visit, but notified of LPA's visit.

The current census is 6. The facility is licensed and approved for 6 non-ambulatory residents, 1 resident may be bedridden and Hospice Waiver for 4 residents. During the visit, LPA was accompanied on a tour of the facility and observed the following:

Physical Plant: The facility is maintained at a comfortable temperature. Pathways inside the facility were free of clutter and obstructions. The common areas such as Living and Dining areas provide adequate seating and lighting. Resident Rooms included adequate lighting, seating, beds with required linens, night stands and appropriate storage. Resident Bathrooms contained adequate paper supplies, space, hand soap, non-slip materials and operable appliances. Water temperature was tested and observed between 105-114 degrees F. within regulation. The facility is equipped with operating smoke detectors and carbon monoxide alarms. LPA observed two fully charged fire extinguishers. The two fire extinguishers did not have tags of last inspection. Staff maintains the fire extinguishers were inspected in June 2023. LPA observed that items such as cleaning supplies, toxins, sharps, and other dangerous items were kept secure inaccessible to residents in care. The facility food supply was observed in good standing and sufficient for the amount of residents in care. Dishes, cups, and utensils were also observed and stored properly. Posters such as: Facility License, Facility Sketch, Long Term Care Ombudsman, See Something Say Something, Theft and Loss Policy, Administrator Certificate, and Resident Rights were posted in a prominent place in the facility. LPA observed Medications are kept secure and inaccessible to unauthorized individuals inside the facility kitchen.

LPA requested to review facility files for staff and residents. LPA was informed that only select staff have access to such records. LPA unable to reach Administrator on file during the visit. LPA was unable to review and records during the visit which poses a potential risk to residents in care.

Based on observations, deficiencies will be cited to address concerns for the facility records and accessibility.

An exit interview was conducted, this report was reviewed, discussed then provided to facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2024 11:27 AM - 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
SAN BERNARDINO, 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: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87755(c)

Inspection Authority of the Licensing Agency: (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and review of records the licensee did not comply with the section cited above by not being able to produce any records for staff or residents. During the visit, staff did not have access to records. Administrator not available for contact to request such records; which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	Administrator/Licensee agrees to contact Community Care Licensing to produce records for both staff and residents. Records such as, Physician's Reports, Needs and Services, Admissions Agreements, Verification of Required Staff Trainings, Proof of Fingerprints/Background Checks/Facility Associations, Health Screenings. These records or proof their of are to be submitted to Community Care Licensing within the next 30 business days.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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