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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881358
Report Date: 04/24/2025
Date Signed: 04/24/2025 04:36:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2024 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240213115944
FACILITY NAME:SUN CITY GARDENSFACILITY NUMBER:
331881358
ADMINISTRATOR:DIANE DOMINGOFACILITY TYPE:
740
ADDRESS:28500 BRADLEY ROADTELEPHONE:
(951) 679-2391
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:74CENSUS: 60DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Georgianna Mendez, Executive DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Due to neglect, a resident sustained pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Georgianna Mendez, Executive Director, and informed them the purpose of LPA's visit. The Department investigation involved interviews with staff and review of records.

It was alleged that due to neglect, a resident sustained pressure injuries while in care. LPA’s records review revealed the following for Resident #1 (R1). R1 had been admitted to Sun City Gardens on June 10, 2023, and resided there until December 10, 2023. A physician’s report dated July 10, 2023, stated R1 was non-ambulatory and noted a history of skin conditions or skin breakdowns, no further details about R1's skin condition were provided.

Facility records included R1’s narrative charting from June 27, 2023, to February 13, 2024. Upon review, LPA found no documentation indicating R1 had sustained pressure injuries.
Continued on LIC9099-C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20240213115944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUN CITY GARDENS
FACILITY NUMBER: 331881358
VISIT DATE: 04/24/2025
NARRATIVE
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On December 10, 2023, R1 was sent to the hospital due to an urgent health condition and did not return to the facility afterward. According to records, R1 remained at a skilled nursing facility until March 15, 2024. A Resident Move Out form dated April 24, 2024, confirmed R1 never returned to Sun City Gardens and officially moved out on May 2, 2024.

Interviews with two staff members who provided care to R1 revealed R1 was non-ambulatory and R1 was able to stand up and walk. In addition, a Pre-placement appraisal dated June 7, 2023, indicated R1 required use of a walker and or wheelchair. Staff frequently reminded R1 to use a wheelchair due to R1’s tendency to move around without it, but neither staff member recalled R1 having pressure injuries during their time at the facility. Information obtained during this investigation did not corroborate the alleged allegation of R1 sustaining pressure injuries while in care.

Based on record reviews and staff interviews, this allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.


An exit interview was conducted where a copy of this report was provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2