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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911117
Report Date: 02/21/2021
Date Signed: 02/21/2021 01:21:40 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: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: 10DATE:
02/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gino Alvarez - CareTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived to conduct a health and safety case management visit. LPA met with caregiver Gino Alverez to discuss the reason for the visit. LPA Colvin toured the facility with Alvarez and observed the following:

LPA Colvin observed the facility to have the required amount of perishable and non-perishable food, utilities are operational, medication for all residents present, and personal hygiene supplies (such as toilet paper and soap). LPA Colvin accounted for all ten residents and briefly interviewed them to ensure all essential needs were being met, such as being provided three meals each day. All residents stated that they are well fed and have their basic needs met. LPA Colvin did not observe any immediate Health and Safety concerns at this time.

An exit interview was conducted with Caregiver Gino Alvarez and a copy of the report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2021
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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