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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:19:56 PM


Document Has Been Signed on 02/22/2023 02:19 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, 1650 SPRUCE ST STE 200 MS29-27
, 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: 5DATE:
02/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Raymond Munsayac, care providerTIME COMPLETED:
02:22 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) Anna Bueno arrived at the facility for the purpose of following up on open complaint #18-AS-20211223163003 requested records. LPA met with care staff Raymond Munsayac who was informed of the reason for today's visit. Munsayac phoned Licensee Ana Stark who was not present in the facility. Stark informed LPA that they will not be able to provide records to LPA during today's visit as the records were not accessible at this time.

On 12/28/2021, LPA Anna Bueno conducted the initial complaint visit to this facility and requested records.
On 12/29/2021, LPA Bueno sent electronic message to Licensee requesting for records and Licensee responded to LPA that they will work on the request on this day.
On 1/13/2022, LPA Bueno sent an electronic message to Licensee following up on the requested records and Licensee sent a response stating that they will work on this today.
On 2/14/2023, LPA Bueno phoned the Licensee about the open complaint and sent an electronic request for Licensee to forward any submitted to any other LPAs between 1/14/22 through today's notification.
During today's call with Licensee, Licensee was unable to verify if records were sent to another LPA at any time.

LPA Bueno was not able to review and/or receive any records related to this complaint on this visit or at any other time LPA Bueno requested for records. LPA observed Staff 1 (S1) has a criminal background clearance but was not associated to this facility. These pose an immediate health and safety risk to residents in care.

Refer to LIC809-D for deficiencies cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Raymond Munsayac.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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 2


Document Has Been Signed on 02/22/2023 02:19 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2023
Section Cited

1
2
3
4
5
6
7
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).
1
2
3
4
5
6
7
Licensee shall submit all requested records in person or electronically to LPA Bueno and/or the San Bernardino Regional office no later than close of business POC date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

LPA was not able to review any records requested for complaint# 18-AS-20211223163003.
8
9
10
11
12
13
14
Type A
02/22/2023
Section Cited

1
2
3
4
5
6
7
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
1
2
3
4
5
6
7
Licensee shall associate S1 to this facility no later than close of business POC date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

LPA Bueno confirmed that S1 has a person number but is not associated to this facility. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2