330911117-8-20-2020-18-AS-EMAN-BSUV9L-20200826161430

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 330911117
Report Date: 08/20/2020
Date Signed: 08/20/2020 04:28:48 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
05/08/2020 and conducted by Evaluator Robbie Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200508140901

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: 9	DATE:	08/20/2020
		UNANNOUNCED	TIME BEGAN:	03:49 PM
MET WITH:	Myrna Cabungan, Administrator		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff slapped resident
Facility failed to provide resident adequate meals
Financial abuse

INVESTIGATION FINDINGS:

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

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 interviews with the Administrator revealed that no staff has ever hit, struck or slapped any resident. Interviews with the care staff revealed that no resident has been slapped. Interviews with resident R1 revealed that staff did not slap R1. LPA could not corroborate that staff slapped R1. The allegation is UNSUBSTANTIATED.
Allegation #2 Interviews with staff revealed that meals are prepared and served to residents three times per day with two snacks. Residents interviewed revealed that adequate meals are served regularly. LPA could find no evidence that adequate meals are not being served to residents. The allegation is therefore UNSUBSTANTIATED.
Continued on next 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: 08/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020

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 2

Control Number 18-AS-20200508140901

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: 08/20/2020

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 #3 Financial abuse- Interviews with the Administrator revealed that no staff has ever asked any resident for money. Interviews with the Administrator and staff revealed that no staff has ever made purchases for residents with residents money. Interviews with residents revealed that staff has never taken money from the residents and that staff does not have access to their banking information. LPA could find no evidence that staff is committing financial abuse with resident funds. 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.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Robbie Johnson	TELEPHONE: (951) 248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2