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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911117
Report Date: 11/06/2020
Date Signed: 11/06/2020 11:57:10 AM

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:
11/06/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carmelina RoxasTIME COMPLETED:
11:52 AM
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Licensing Program Analyst (LPA) Natalie Gayoso contacted the facility to initiate a case management visit via telephone due to COVID-19. LPA identified herself and discussed the purpose of the call with caregiver Carmelina Roxas. Administrator was no available at the time.

LPA was unable to conduct a Health and Safety tele-visit due to facility not having any method to do so. Ms. Roxas stated that all 10 residents are currently still at the facility and doing well. At this moment there is no plan or information as to when and where residents will move to. Ms. Roxas stated she is aware that the names and locations of where their current residents relocate to must be submitted to CCL.

An exit interview was conducted where this report was discussed via telephone with Ms. Roxas and a copy submitted via email.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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