331881358-5-18-2025-18-AS-APAO-DK4PUS-20250731113802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881358
Report Date: 05/18/2025
Date Signed: 05/18/2025 03:01:32 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
08/19/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 18-AS-20240819145843

FACILITY NAME:	SUN CITY GARDENS		FACILITY NUMBER:	331881358
ADMINISTRATOR:	DIANE DOMINGO		FACILITY TYPE:	740
ADDRESS:	28500 BRADLEY ROAD		TELEPHONE:	(951) 679-2391
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	74	CENSUS: 58	DATE:	05/18/2025
		UNANNOUNCED	TIME BEGAN:	08:22 AM
MET WITH:	Brenda Sanchez - Resident Services Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not provide resident with modified diet as prescribed.
Staff did not ensure resident’s room was adequately cleaned.
Staff did not assist resident with personal hygiene care.
Staff did not dispense resident’s medication as prescribed.
Staff did not refill resident's medication in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPA met with Brenda Sanchez and explained reason for the visit.

LPA conducted physical plant tour at 8:55 AM, requested copies of facility documents relevant to the investigation at 9:38 AM, reviewed records between 10:00 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 1:30 PM. Regarding the allegation that Staff did not provide resident with modified diet as prescribed, it was alleged that staff not making sure thickened water is available for Resident #1 (R1) to drink because R1 was having trouble swallowing. LPA's record review today revealed that R1 was admitted on 11/22/22 had trouble swallowing and was prescribed to be given honey thick liquid on 01/09/24 by the Hospice Doctor. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that when they were taking care of R1 and received the order, they gave R1 thickened water and orange juice regularly every day and even leave a thickened liquid on R1's room.
(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025

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 3

Control Number 18-AS-20240819145843

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: 05/18/2025

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff did not ensure resident’s room was adequately cleaned, it was alleged that R1's room had urine multiple urine stains. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that they regularly do a light cleaning on everyone's room and the housekeeper do general cleaning of everyone's room once a week. LPA's interview with housekeeping staff yesterday 05/17/25, revealed that they shampoo R1's room whenever requested by the former Resident Service Director (RSD) but denied that it had urine stains. LPA's interview with six (6) Assisted Living (AL) residents revealed six (6) out of six (6) residents state that their room are being cleaned regularly by staff and do general cleaning once a week.

Regarding the allegation that Staff did not assist resident with personal hygiene care, it was alleged that staff did not make sure that R1's hands were clean and did not file R1's nails and staff also did not wash R1's face or help brush R1's teeth. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that during their shift (AM) they regularly assist R1 getting up to bed, clean, brush teeth, shower during schedule days and dress and groom before breakfast every day. They stated however that cutting and filing nails were not part of their duty as it may hurt R1 so they had to bring R1 to a podiatrist or a salon. Further, when R1 was admitted to Hospice care, the hospice staff were doing R1's bathing and grooming, including but not limited to nail trimming and filing, shaving, etc., LPA’s record review of hospice notes confirmed that the hospice staff were assisting on R1's ADLs.

Regarding the allegation that Staff did not dispense resident’s medication as prescribed, it was alleged that R1 was being over medicated because staff were dispensing medications as directed by an old doctor’s order and not the newest order. LPA's record review revealed that since R1 started on Hospice services, it was the hospice staff checking and reconciling R1's medication and due to R1's condition medication orders changed faster than usual. Further review revealed that all the medications administered to R1 from the period August 2024 up to the time of R1's passing on October 2024 were given as prescribed.

(continued on LIC 9099-C-2)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20240819145843

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: 05/18/2025

NARRATIVE

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(continued from LIC 9099-C)

Regarding the allegation that Staff did not refill resident's medication in a timely manner, it was alleged that R1 ran out of heart medication but staff did not inform RP until one week later. LPA's record review revealed that R1 was using facility non-contracted pharmacy, in which the family member and/or responsible party are the ones responsible for contacting the pharmacy for refills. Further review also revealed that R1 did not miss any regularly prescribed medication from July 2024 until the time of R1's passing on October 2024.

Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025

LIC9099 (FAS) - (06/04)

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