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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911117
Report Date: 10/27/2020
Date Signed: 10/27/2020 12:22:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 GARDENSFACILITY NUMBER:
330911117
ADMINISTRATOR:MYRNA CABUNGANFACILITY TYPE:
740
ADDRESS:4846 DOANE AVE.TELEPHONE:
(951) 376-1361
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:12CENSUS: 10DATE:
10/27/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Gino Alverez, CaregiverTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Naisha Kendrix and Natalie Gayoso conducted a case management visit to verify compliance with Health & Safety Code Section 1569.38. LPAs met with Caregiver, Gino Alverez, and stated the reason for the visit. Gino phoned the Administrator Myrna Cabungan, who was unavailable for the visit.

During the tour of the facility it was also observed that the facility did have a posting as required by law of Accusations # 8220149402, # 822014942B, # 822014942C,


# 822014942D, # 822014942BE, # 822014942F, # 822014942G, and #822014942H issued on 10/16/2020. An additional copy of the Accusations are being provided to the facility at the time of this visit, and civil penalties will be assessed against a facility which fails to take corrective action within described time periods.

Per California Health and Safety Code section 1569.38, you are hereby notified that a $100 civil penalty per day will be assessed until the violation is corrected. This assessment will not exceed $100/day regardless of the number of notices the licensee fails to send. The total penalty for a continuous violation shall not exceed $5,000.00.

It was observed that
I. The facility failed to provide written notification as required by H&S Code 1569.38(b) to the residents/resident's responsible party within the required 10 days.
II. The facility failed to provide written notification as required by H&S Code 1569.38(c) to the local Long-Term Care Ombudsman. within the required 10 days.
III. The following information shall also be included in the information provided:
· The name and contact information of the local Long-Term Care Ombudsman.
The name and contact information of the Community Care Licensing Division (local office)
SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Naisha KendrixTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/27/2020
NARRATIVE
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· The facility was issued a civil penalty of $100 a day which is imposed until the facility complies with a maximum of $5000.
· A statement directing the reader to contact the Community Care Licensing Division on the status of the license.

Refer to LIC 421 for civil penalties issued during the visit.

An exit interview was conducted where this report, LIC 809D, civil penalties, and appeal rights were provided to Mr. Alvarez.
SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Naisha KendrixTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2020
Section Cited

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Posting of licensing reports; disclosure to new residents Upon providing the notice prescribed in subdivision (b), the licensed residential care facility shall also post a written notice, in a conspicuous location in the facility. This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee failed to ensure the Accusations served by the department are posted in a conspicuous location in the facility. This poses a potential health & safety
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CONT. risk to residents in care. LPA did not observe the accusations posted in a conspicuous place in the facility. Licensee did not notify the resident's responsible parties of accusations.

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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: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Naisha KendrixTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3