330911117-6-23-2020-18-AS-EMAN-BRY2BP-20200728171527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 330911117
Report Date: 06/23/2020
Date Signed: 06/23/2020 04:45:41 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
04/24/2020 and conducted by Evaluator Robbie Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200424155016

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:	12	CENSUS: 10	DATE:	06/23/2020
		UNANNOUNCED	TIME BEGAN:	02:46 PM
MET WITH:	Administrator Myrna Cabungan		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff person is verbally abusive to the resident.
The residents needs are not being met by staff person.
Staff does not have training in transferiring the resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Robbie Johnson contacted the facility via telephone due to COVID-19 to deliver findings regarding the above allegations. LPA identified herself and discussed the purpose of the call and the elements of the above allegations with Administrator Myrna Cabungan.

Allegation #1 an interview with the reporting party revealed that resident R1 was verbally abused by staff. Interviews with several staff reveal that no staff has verbally abused R1 or any resident. LPA could not corroborate that staff was verbally abusive to a resident. The allegation is UNSUBSTANTIATED.

Allegation #2 An interview with the reporting party revealed that resident R1 needs were not being met. Interviews with several staff reveal that staff assist all residents with activities of daily living including assitance with bathing, dressing, toileting and food. LPA could find no evidence that staff is not meeting the needs of the residence. The allegation is unsubstantiated. *continued on following page**

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Robbie Johnson	TELEPHONE: (951) 248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200424155016

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: 06/23/2020

NARRATIVE

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Allegation #3 Interviews with the reporting party revealed that staff does not use a hoyer lift when transferring resident R1. Interviews with several staff revealed that a hoyer lift is not present in the facility and that staff assited R1 in transferring without the use of a hoyer lift. LPA could not corroborate that staff is not trained in transferring a resident. The allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred.

A copy of this report was reviewed with and provided to the Administrator.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Robbie Johnson	TELEPHONE: (951) 248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

LIC9099 (FAS) - (06/04)

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