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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 330911117
Report Date: 07/17/2023
Date Signed: 07/17/2023 01:05:55 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2020 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200429131500
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: 0DATE:
07/17/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Staff and designee not available, facility closed 3/4/2021TIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident wandered away from facility due to lack of supervision
Facility did not notify resident's authorized rep that resident wandered away
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tricia Danielson phoned facility designee Myrna Cubungan in an effort to deliver findings of an investigation into the allegations listed above. LPA was unable to make contact with Cubangan on several occasions and although LPA requested return calls, one was not received.
LPA attempted to obtain facility records pertaining to Resident #1(R1) but was unable to make contact with facility designee Cubangan in order to do so. Due to Cubangan's lack of response to LPA's inquiries, LPA was also unable to interview staff. Several requests were made for a police report regarding the incident at Riverside City Police Department as well as Riverside Sheriff's Department but no report was found. R1 was unable to be interviewed. One witness was interviewed and they were unable to identify R1's authorized representative. The allegations "Resident wandered away from facility due to lack of supervision" and "Facility did not notify resident's authorized representative that resident wandered away" are unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
An exit interview was not able to be conducted however, a copy of this report along with LIC 811- Confidential Names List was sent via email to designee at VGUINTO@SBCGLOBAL.NET.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
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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