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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911117
Report Date: 12/09/2020
Date Signed: 12/09/2020 11:51:41 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:
12/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff, Gino AlverezTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Naisha Kendrix and Licensing Program Manager (LPM) Efren Malagon arrived to conduct a case management visit. LPA met with caregiver Gino Alverez to discuss the reason for the visit. Alverez contacted the landlord for the address, Juliet Meer who arrived during the visit. There were ten residents in care at the time of the visit, none were receiving hospice services.

LPA and LPM toured the facility, spoke with the staff, and the residents in care. LPA observed the required amount of food, utilities are operational, and there were no Health and Safety concerns at this time.

LPA and LPM discussed the care plan for the ten residents remaining at the facility with the property owner Juliet Meer. Meer stated that she was informed by the licensee that the facility will be closing within 60 days. Meer will provide care and supervision to all ten residents until the residents are relocated or another license is issued by the Department.

An exit interview was conducted where this report was reviewed and will be emailed to Meer and the licensee.


SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Naisha KendrixTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
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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