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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 12/28/2021
Date Signed: 12/28/2021 03:53:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 4DATE:
12/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Margarita StarkTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility for the purpose of conducting a health and safety visit in relation to complaint number 18-AS-20211223163003. During the visit LPA toured the facility with Staff inside and out.

Residents in care and visitors were present during today's visit. LPA observed that residents appeared to be safe with no imminent health/safety concerns observed. No health/safety hazards were observed. LPA inspected the outside perimeter of the facility and observed no health/safety hazards. There was a sufficient amount of staff present at the facility to provide care for clients. LPA inspected facility food supplies and observed an adequate supply of perishable and non-perishable food. The needs of the residents in care appear to be met during this inspection.

Administrator Stark left the facility before the conclusion of the visit but was advised that the exit interview was conducted and a copy of this report was discussed with Staff.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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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