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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881128
Report Date: 04/15/2021
Date Signed: 04/15/2021 12:29:21 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:
331881128
ADMINISTRATOR:CANTORIA, ROBERTFACILITY TYPE:
740
ADDRESS:4846 DOANE AVE.TELEPHONE:
(951) 376-1361
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:12CENSUS: 0DATE:
04/15/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Robert CantoriaTIME COMPLETED:
12:42 PM
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Licensing Program Analysts (LPAs) Natalie Gayoso and Anna Bueno conducted an announced visit for the purpose of closure. LPAs met with administrator Robert Cantoria.

LPAs toured the facility both inside and outside with administrator. LPAs verify that there were no residents residing at the facility and that all residents were relocated.

The administrator will mail in the original license to CCL at 1650 Spruce St. Suite 200, Riverside, CA 92507.

Administrator was advised that the license would be closed effective today, April 15, 2021. A letter informing of the closure will be sent.

An exit interview was conducted where this report was discussed and provided to the administrator.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
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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