330911117-7-21-2021-18-AS-EMAN-C5QTCK-20210809143652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 330911117
Report Date: 07/21/2021
Date Signed: 07/21/2021 04:14:51 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
10/29/2019 and conducted by Evaluator Natalie Gayoso

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20191029141531

FACILITY NAME:	LA SIERRA GARDENS		FACILITY NUMBER:	330911117
ADMINISTRATOR:	MYRNA CABUNGAN		FACILITY TYPE:	740
ADDRESS:	4846 DOANE AVE.		TELEPHONE:	(951) 376-1361
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY:	0	CENSUS: 0	DATE:	07/21/2021
		UNANNOUNCED	TIME BEGAN:	02:26 PM
MET WITH:	N/A		TIME COMPLETED:	03:16 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Diabetic resident has an infection requiring hospitalization.
The administrator cannot be reached.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Natalie Gayoso was unable to conduct a visit to meet with staff to deliver findings for the above allegation due to facility closure on 2/24/2021.The department investigation included file review, interviews with staff/residents/witnesses, and review of pertinent records.

Allegation: Facility staff failed to provide assistance to Resident #1 (R1) in obtaining medical care.
The Department investigation consisted of interviews with staff, family, and pertinent witnesses with information pertaining to the allegation. The interviews revealed R1 was admitted to the facility on July 11, 2019. S2 reported that R1 had not been evaluated by a physician and that R1 was starting to show change in condition. S3 reported that a primary physician was never assigned to R1 and that no one was caring for R1’s medical needs. In addition, S1 reported that R1 had not been seen by an Ophthalmologist to address vision issues. As of February 5, 2020, it was reported that R1 had still not received assistance in meeting R1 medical needs. Based on the evidence the allegation that facility staff failed to provide assistance to R1 in obtaining medical care is substantiated.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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

Control Number 18-AS-20191029141531

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
	VISIT DATE: 07/21/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: The administrator cannot be reached.
Interview with the Administrator revealed they have not been involved with the facility as of August 2020 and have not ties or interest with the facility. A new owner had purchased the facility back in 2017 and they did not work under the new owner. The new owner was only using them for their administrator license. Based on interview the allegation administrator cannot be reached is substantiated.

Based on interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations Title 22 Division 6 & Ch. 8 are being cited on the attached LIC 9099D

Due to facility's closure, LPA sent complaint investigation report via certified mail.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20191029141531

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: 07/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/22/2021 Section Cited CCR 87465(a)(1-2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed...(1)The licensee shall arrange...for medical and dental care...(2)The licensee shall provide assistance in...medical and dental needs... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility closed 2/24/2021; unable to determine plan of correction.
	8 9 10 11 12 13 14	Based on interviews and records review it was found that facility failed to provide assistance to R1 in obtaining medical care. R1 did not receive medical care for their vision issues, as recommended by a physician. This is an immediate health and safety hazard to residents in care.	8 9 10 11 12 13 14
Type A 07/22/2021 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	Administrator - Qualifications and Duties(a)All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility closed 2/24/2021; unable to determine plan of correction.
	8 9 10 11 12 13 14	Based on interviews with Administrator it was found that the administrator has not been involved with the facility since August 2020 and new facility owner has been using administrator's license. This is an immediate health and safety risk for residents in care	8 9 10 11 12 13 14

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3