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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911117
Report Date: 02/24/2021
Date Signed: 02/24/2021 04:16:16 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: DATE:
02/24/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Gino AlvarezTIME COMPLETED:
04:30 PM
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Regional Manager (RM) Leslie Mendiveles and Licensing Program Analyst (LPA) Natalie Gayoso conducted an unannounced visit at the above referenced facility, on today's date, to deliver an Accusation (Appointment of Temporary Manager) to Licensee Virgilio and Milagros Guinto. RM and LPA were greeted by facility staff Gino Alvarez

RM Leslie Mendiveles explained the purpose of today's visit and the meaning of the accusation which indicates that as of February 24, 2021, the facility is determined to be in a condition in which continued operation by Licensees or their representatives presents a substantial probability of imminent danger of serious physical harm or death to residents of the facility, as follows:

Licensees have been absent from the facility.
Licensees or their representatives have been uncooperative in their responsibilities prior to closure.
Facility administrator Myrna Cabungan’s Administrator Certificate was forfeited or revoked and she was excluded from all Department-licensed facilities and thus there is not currently anyone present who is qualified to be overseeing the facility’s operation.

In addition, the Department has appointed R2R Ventures, LLC as the temporary manager of the facility as licensees are unwilling or unable to comply with Health and Safety Code requirements regarding the safe and orderly relocation of residents as ordered to do so by the department or when otherwise required by law.

The written accusation and order was provided to facility staff Gino Alvarez. Licensees were not present.

Notice to request hearing to contest appointment of Temporary Manager was provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
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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