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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911117
Report Date: 02/22/2021
Date Signed: 02/22/2021 10:29:12 AM

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:
02/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Gino AlvarezTIME COMPLETED:
10:36 AM
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Licensing Program Analyst (LPA) Natalie Gayoso arrived to conduct a health and safety case management visit. LPA met with caregiver Gino Alverez to discuss the reason for the visit. There were 3 caregivers and ten residents in care at the time of the visit.

LPA toured the facility and observed the required amount of perishable and non-perishable food, utilities are operational, medication for all residents’ present, and personal hygiene supplies. LPA did not observe any Health and Safety concerns at this time.

An exit interview was conducted, and report was reviewed with Caregiver Gino Alvarez. Copy of report will be mailed.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
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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