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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880570
Report Date: 12/21/2021
Date Signed: 12/21/2021 12:11:29 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:
12/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:"Margarita" Ana Stark - Licensee/AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of following up on an open complaint investigation (#18-AS-20200325093433) and conducting additional interviews. During LPA Colvin's inspection today, LPA Colvin observed the following violations of Title 22 Regulations and Health and Safety Code:
  • Unassociated Staff - LPA Colvin observed that 1 of 2 staff (S1) present at the facility during today's inspection was not associated to the facility. LPA Colvin confirmed that S1 did have fingerprint clearance, but has been working part time at the facility for three months and has not had their fingerprint clearance transferred to this facility. Deficiency cited. LPA Colvin previously cited this facility for the same violation on 5/4/21. Since this is the facility's second violation within a 12 month period, civil penalties are being assessed in the amount of $100 per day, with a maximum of 30 days instead of 5. LPA Colvin will be citing for the maximum of 30 days, as S1 has been working at the facility for 3 months. $100 a day x 30 days = $3,000 in civil penalties being assessed.

  • Construction to Building - During LPA Colvin's tour of the facility, LPA Colvin observed that the back master bedroom (cleared for bedridden residents), has had two walls and a sliding glass door installed halfway through the room, sectioning off another make-shift room, which LPA Colvin observed to be fully furnished with a bed. LPA Colvin observed that this construction was not present during her last inspection at the facility on 5/4/21, and additionally, LPA Colvin did not observe any notes in LPA Colvin's system showing that the Licensee had contacted Community Care Licensing (CCL) about the construction, nor that a new floor plan had been submitted. Additionally, this change would require approval from the Fire Marshall, as the structure may affect the facility's fire clearance. Deficiency cited.

  • Licensing Fees - LPA Colvin observed that the Licensee has not paid their annual fees for the year.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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 4
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
RIVERSIDE, CA 92507
FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570
VISIT DATE: 12/21/2021
NARRATIVE
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These fees were due on the anniversary of the license, in February. The Licensee has additionally accrued a late charge due to the fees being overdue. As of 12/21/21, the Licensee owes $742. Deficiency cited.
  • Unsafe Walkway/Pavement - Upon LPA Colvin's arrival to the facility, LPA Colvin observed that there was a large section of pavement in the driveway, approximately 4 - 5 feet in length, which was broken and cracked, with some areas uneven, causing the ground to abruptly change height. LPA Colvin used a writing pen to measure the difference in the height of the pieces of pavement, and estimates the difference to be at least 2 inches. This is a potential hazard to the residents, staff, and visitors, as someone could trip and fall while walking up to the facility. LPA Colvin notes that the property/parcel of land has multiple properties on it, but the driveway is included in the facility's sketch, and therefore is included in the license and is considered part of the facility and the responsibility of the Licensee. Deficiency cited.


An exit interview was conducted and a copy of this report, LIC809D, civil penalty forms and appeal rights, along with LIC 811 was provided to to Licensee/Administrator "Margarita" Ana Stark.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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
RIVERSIDE, CA 92507

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2021
Section Cited

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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)
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This requirement was not met by: Based on record review and observation, the Licensee did not comply with the above requirement with one staff. LPA Colvin observed that S1 did not have their criminal record clearanced transferred to the facility. This is an immediate safety risk for all residents.
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Type B
01/11/2022
Section Cited

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Alterations to Existing Building or New Facilitie: (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by"
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Based on observations and record review, the Licensee did not comply with the above regulation with one room of the facility. LPA Colvin observed the master bedroom to have two new walls installed to seperate the room. CCL was not notified of the construction. This is a potential safety risk to residents in care.
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Correction date of 1/11/22.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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
RIVERSIDE, CA 92507

FACILITY NAME: ALTA LOMA GARDENS RESIDENTIAL CARE #1
FACILITY NUMBER: 361880570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2022
Section Cited

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Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met as evidenced by:
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Based on record review, the Licensee did not comply with the above regulation with the facility's licensing fees. LPA Colvin observed that the Licensee owes $742. This is a potential safety risk for all residents, as the license may be revoked.
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Type B
01/11/2022
Section Cited

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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by:
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Based on observatons, the Licensee did not comply with the above regulation with one area of the facility. LPA Colvin observed a 4-5 foot area of concrete in the driveway which was cracked and uneven, with height differences of approximately 2 inches. This is a potential safety risk to residents & visitors
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4