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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 330911117
Report Date: 07/29/2020
Date Signed: 07/29/2020 01:14:37 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2020 and conducted by Evaluator Robbie Johnson
COMPLAINT CONTROL NUMBER: 18-AS-20200410152617
FACILITY NAME:LA SIERRA GARDENSFACILITY NUMBER:
330911117
ADMINISTRATOR:MYRNA CABUNGANFACILITY TYPE:
740
ADDRESS:4846 DOANE AVE.TELEPHONE:
(951) 376-1361
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:12CENSUS: 9DATE:
07/29/2020
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Myrna Cabungan, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not adequately providing for resident's care needs
Staff make inappropriate comments in front of residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Robbie Johnson contacted the facility via telephone due to COVID-19 to deliver findings regarding the above allegations. LPA identified herself and discussed the purpose of the call and the elements of the above allegations with Administrator Myrna Cabungan.

Allegation #1 Interviews with the reporting party revealed that staff is not providing adequae care for resident R1. Interviews with the Administrator revealed that R1 was not bedridden and was able to move with assistance from bed to wheelchair. Interviews with several staff reveal that staff (S1) assisted (R1) with activities of daily living including bathing, dressing, toileting. Further interviews revealed that additional staff assisted R1 with food. LPA could find no evidence that staff is not meeting the care needs of R1. The allegation is unsubstantiated

Allegation #2 Interviews with the reporting party revealed that staff make inappropriate comments in front of residents. Interviews with staff revealed that inappropriate comments were not made in front of residents. Interviews with residents revealed that staff has not made inappropriate comments in their presence. LPA could not corroborate that staff made inappropriate comments to residents. The allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Robbie JohnsonTELEPHONE: (951) 248-0304
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20200410152617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LA SIERRA GARDENS
FACILITY NUMBER: 330911117
VISIT DATE: 07/29/2020
NARRATIVE
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32
A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred.

A copy of this report was reviewed with and provided to the Administrator Myrna Cabungan

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Robbie JohnsonTELEPHONE: (951) 248-0304
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2