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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 10/16/2024
Date Signed: 10/16/2024 03:50:25 PM


Document Has Been Signed on 10/16/2024 03:50 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
SAN BERNARDINO ASC, 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:
(909) 244-9031
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: DATE:
10/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Caregiver, Raymond MunsayacTIME COMPLETED:
03:57 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to this facility to initiate an investigation of complaint number: 56-AS-20241015093925. LPA met with Caregiver, Raymond Munsayac.


During today's visit, LPA conducted interviews with residents, staff, obtained and reviewed facility records, and did a walk-through of the facility. LPA found the following issues:
  • Staff Personnel record not accessible and readily available for review.
These pose an potential health and safety risk to residents in care. Refer to LIC 809D for deficiencies cited.

An exit interview was conducted where this report, LIC809D, and appeal rights were discussed with and provided to Caregiver, Raymond Munsayac.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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 10/16/2024 03:50 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
SAN BERNARDINO ASC, 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: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2024
Section Cited
CCR
87755(c)

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87755(c) The licensing agency shall have the.. audit...resident or..facility..demand during normal business..requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement is not met as evidenced by:
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Administrator stated she will update the personnel record and ensure they are accessible for upon request. Administrator stated she will review the regulation cited and submit a statement of understanding to LPA via email by 10/29/2024.
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Based on observation, and interviews the administrator did not comply with the section cited above by not maintaining personnel records and having them accessible for LPAs review which poses a potential health, safety or personal rights risk to persons 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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