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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911117
Report Date: 11/19/2020
Date Signed: 11/19/2020 12:08:32 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:
11/19/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Gino AlvarezTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Williams arrived at the facility in order to conduct a case management visit. LPA met with Caregiver, Gino Alvarez, and discussed the purpose of the visit. The administrator was not available at the time of visit; however, LPA interviewed Administrator, Myrna Cabungan, over the phone.

Alverez and Cabungan confirmed that the Accusations were posted inside the facility. LPA toured the facility and observed that Accusations # 8220149402, # 822014942B, # 822014942C, # 822014942D, # 822014942BE, # 822014942F, # 822014942G, and #822014942H issued on 10/16/2020, were posted in a common place in the facility.

LPA interviewed Cabungan over the phone who stated that the facility is still planning on closing; however, she is unaware of the specific date of facility closure. Cabungan stated that a letter to surrender the facility's license was sent to Sacramento. LPA advised Cabungan that a statement indicating that the facility plans to close should be sent to the Riverside Regional Office. LPA also advised Cabungan that the facility should provide each resident or the resident's responsible person with a written notice no later than 60 days before the intended eviction, in accordance with Title 22 Regulations, Section 87224. Cabungan stated that she is unsure of where the resident's will be relocating at this time.

During the tour of the facility, LPA observed residents eating and utilities to be operating. LPA interviewed several resident's who stated that they had no concerns of the facility. There appears to be no immediate health and safety concerns that were observed at the time of visit.

An exit interview was conducted where this report was discussed and a copy was provided to Alvarez.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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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