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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 330911117
Report Date: 07/30/2020
Date Signed: 07/30/2020 11:34:41 AM



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
04/14/2020 and conducted by Evaluator Robbie Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200414115831
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:
07/30/2020
UNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Myrna Cabungan, AdministratorTIME COMPLETED:
11:43 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff illegally evicted resident
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 allegation. LPA identified herself and discussed the purpose of the call and the elements of the above allegations with Administrator Myrna Cabungan.

During the course of the investigation LPA conducted interviews with staff and residents. Interviews with the reporting party revaled that staff verbally evicted resident R1 by stating R1 can no longer live in the facility. Interviews with the administrator revaled that resident R1 was never served an eviction in writing or verbally. Interviews with staff revealed that R1 was never told that R1 can no longer live in the facility. Due to conflicting interviews LPA could not corroborate that facility staff illigally evicted resident. The allegation is UNSUBSTANTIATED. 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 via email.
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: 07/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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