<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:20:47 PM


Document Has Been Signed on 04/03/2024 03:20 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
CCLD Regional Office,
, CA



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: 6DATE:
04/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Ana Stark Pleitez, AdministratorTIME COMPLETED:
03:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to conduct a case management visit to clear deficiency. LPA was greeted at the door by facility staff and Administrator Ana Stark Pleitez was present. Currently there are six (6) residents in care. The following documents were requested to be viewed for staff and residents; records such as, Physician's Reports, Needs and Services, Admissions Agreements, Verification of Required Staff Training's, Proof of Fingerprints/Background Checks/Facility Associations, Health Screenings. These records or proof their of were to be submitted to Community Care Licensing by March 13, 2024. LPA Delgado requested and reviewed five (5) of six (6) residents files and all documents requested were not in files. There is no file for 6th Resident. LPA requested to review five (5) staff files and three (3) of five (5) files were available to be reviewed and all documents requested were not in files.

Based on the information received during this visit today, civil penalties assessed are $2100 and will be issued for Failure to Correct per Title 22, Division 6 of The California Code of Regulations.

This LIC 809 report, LIC811, LIC421FC, and Appeal Rights was reviewed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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 1