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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 330911117
Report Date: 04/06/2021
Date Signed: 04/06/2021 04:51:41 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
10/16/2019 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191016161830
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:0CENSUS: 1DATE:
04/06/2021
UNANNOUNCEDTIME BEGAN:
04:32 PM
MET WITH:Robert CantoriaTIME COMPLETED:
04:52 PM
ALLEGATION(S):
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Facility staff are not assisting resident with hygiene needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natalie Gayoso contacted the facility via telephone due to COVID-19 to deliver findings for the above allegation. LPA identified herself and discussed the purpose of the call with Administrator, Robert Cantoria.

The investigation consisted of interviews with relevant parties. The allegation indicates facility staff are not assisting resident with hygiene needs. Interviews with staff revealed that staff have been giving Resident #1 (R1) a sponge bath once a week due to R1 not being able to stand in shower. LPA interviewed the Administrator stated that R1 was not prescribed sponge baths and there is no reason for R1 not to be bathed properly in the showered.
Based on LPAs interviews which were conducted , the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, isbeing cited on the attached LIC 9099D
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
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 3
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
10/16/2019 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191016161830

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:0CENSUS: 1DATE:
04/06/2021
UNANNOUNCEDTIME BEGAN:
04:32 PM
MET WITH:Robert CantoriaTIME COMPLETED:
04:52 PM
ALLEGATION(S):
1
2
3
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8
9
Facility staff are not distributing medication as prescribed
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Natalie Gayoso contacted the facility via telephone due to COVID-19 to deliver findings for the above allegation. LPA identified herself and discussed the purpose of the call with Administrator, Robert Cantoria.

The investigation consisted of interviews with relevant parties. The allegation indicates facility staff are not distributing medication as prescribed. Interviews with staff revealed that R1's medication is distributed as prescribed. Administrator stated R1 was discharged from hospice in August 2019. Since discharge, staff have continued to provide R1 with medication as presbribed by doctor.
Based on the information obtained, the allegation is UNSUBSTANTIATED. A finding of Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
An exit interview was conducted and this report, LIC 9099D, and appeal rights were discussed via telephone and a copy was provided via email to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20191016161830
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2021
Section Cited
CCR
87464(f)(4)
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Basic Services (f) Basic services shall at a minimum include:(4)Personal assistance and care as needed ...with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications....This requirement was not met as evidenced by:
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The licensee will conduct an
in-service training on how to meet the residents care needs, including bathing, and provide a sign in sheet from the training by POC date
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Based on interviews staff failed to properly bath R1 and provide hygiene needs. This poses an immediate health and safety risk to resident in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3