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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911117
Report Date: 02/08/2021
Date Signed: 02/08/2021 11:50:49 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: 11DATE:
02/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carmelina "Ana" RoxasTIME COMPLETED:
11:48 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 "Ana" Roxas. Administrator was no available at the time.

The LPA conducted a virtual tour of the home via Facetime. LPA observed the required amount of food, utilities are operational, and there were no Health and Safety concerns at this time. Ms. Roxas stated the residents are doing well and at this moment there is no plan or information as to when and where residents will be moved 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: 02/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021
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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