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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881358
Report Date: 04/29/2025
Date Signed: 04/29/2025 10:20:37 AM

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
03/25/2024 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240325081849
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: 59DATE:
04/29/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Georgianna Mendez, Executive DirectorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained unexplained 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, who was informed of today's visit. The Department investigation involved interviews with staff and review of records.

It was alleged resident sustained unexplained injuries while in care. According to records reviewed by LPA and interviews conducted with staff, it was determined that Resident #1 (R1) was a non-verbal, bedridden and receiving hospice care since 2021. R1 required a two-person assist due to their frail condition. Two (2) current staff members who provided care to R1 during R1’s residency at the facility were interviewed as part of the investigation. Both staff members confirmed that R1’s bedridden condition required a 2-person assist and stated that caregivers at the facility underwent specialized training (repositioning and feeding position) provided by the hospice agency for every resident entering hospice care. However, neither staff member was able to provide an explanation for the bruising observed on R1.
Continued on LIC9099-C.....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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-20240325081849
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: 04/29/2025
NARRATIVE
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The LPA reviewed hospice notes dated from September 29, 2023, to February 27, 2024, and found that hospice nurses consistently educated caregivers and medical technicians during each visit to the facility. The topics covered included repositioning techniques, aspiration precautions, and R1's feeding position.

LPA interviewed two (2) hospice nurses who observed R1’s bruises. Both nurses confirmed the bruises were likely from someone’s hand, but neither nurse was able to tell what or who caused the bruises. Both nurses asked the facility caregivers about R1’s bruises at the time of the discovery, but none of the caregivers had any knowledge of events or incidents that could explain R1’s bruises.

Based on LPA’s record reviews and staff interviews, the investigation did not reveal corroborating evidence to determine the cause or source of R1’s bruises. Therefore, the allegation is determined to be Unsubstantiated. A finding of Unsubstantiated indicates that while the allegation may have occurred or been valid, there is not a preponderance of evidence to conclusively prove that the alleged violation took place.

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: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2