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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881358
Report Date: 06/07/2025
Date Signed: 06/07/2025 03:25:45 PM

Substantiated


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
05/21/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 18-AS-20240521162029
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: 62DATE:
06/07/2025
UNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Brenda Sanchez - Resident Services DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff do not answer residents' call buttons in a timely manner

Staff do not ensure that residents' showering needs are met

Staff do not ensure that residents are provided laundry service
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
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12
13
Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit at this facility to investigate the above allegations. LPA met with Resident Services Director (RSD) Brenda Sanchez and explained the reason for the visit.

LPA conducted physical plant tour at 9:02 AM, requested copies of facility documents relevant to the investigation at 9:43 AM, reviewed documents between 9:45 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 1:30 PM. Regarding the allegation that Staff do not answer residents' call buttons in a timely manner, it was alleged that residents are not having their call buttons answered for extended periods of time. LPA Shaw Ross' interview with three (3) residents on 05/28/24 and LPA's interview today with seven (7) residents or more than 10% of current census revealed that five (5) out of ten (10) residents interviewed stated that staff comes more than an hour after pressing their call button. Three (3) residents interviewed stated that they have not used the call button at all. Only two (2) residents interviewed stated that staff come on time within thirty (30) minutes. (continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2025
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 5
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
05/21/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 18-AS-20240521162029

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: 62DATE:
06/07/2025
UNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Brenda Sanchez - Resident Services DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handles residents in a rough manner

Staff spoke inappropriately to resident

Staff do not ensure that residents are hydrated

Staff did not ensure that a resident's incontinence needs were met

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit at this facility to investigate the above allegations. LPA met with Resident Services Director (RSD) Brenda Sanchez and explained the reason for the visit.

LPA conducted physical plant tour at 9:02 AM, requested copies of facility documents relevant to the investigation at 9:43 AM, reviewed documents between 9:45 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 1:30 PM. Regarding the allegation that Staff handles residents in a rough manner, it was alleged that Staff #1 (S1) handled residents in a rough manner, LPA's interview with seven (7) residents or more than 10% of current census revealed that seven (7) out of seven (7) residents did not experience or witness R1 being rough on any resident.

(continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20240521162029
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: 06/07/2025
NARRATIVE
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3
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5
6
7
8
9
10
11
12
13
14
15
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20
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23
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26
27
28
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32
(continued from LIC 9099-A)

Regarding the allegation that Staff spoke inappropriately to resident, it was alleged that S1 threatened Resident #1 (R1). LPA's interview with four (4) staff today revealed that R1's first language was not English and could be misconstrued as aggressive but that was S1's normal voice. Four (4) out of four (4) staff interviewed stated that they did not witness R1 threatening or spoke inappropriately to any resident. LPA's interview with seven (7) residents or more than 10% of current census revealed that seven (7) out of seven (7) residents did not experience or witness R1 threatening any resident.

Regarding the allegation that Staff do not ensure that residents are hydrated, it was alleged that Resident #1 (R1) was screaming and needed water. LPA's record review revealed that R1 was admitted at the facility on 04/10/24 and passed away on 05/24/24. LPA's interview with four (4) staff today revealed that they always make sure that all residents have access to and provide drinking water to all residents. LPA's interview with seven (7) residents today or more than 10% of the current census revealed that seven (7) out of seven (7) residents stated that they do not have issues with drinking water and were provided by the staff all the time.

Regarding the allegation that Staff did not ensure that residents' incontinence needs were met, it was alleged that R1 was screaming due to being soaked wet for a long period of time. LPA attempted to interview the staff that may have witnessed the incident but the staff no longer works here. LPA's interview with five (5) incontinent residents today between 11:30 AM to 1:30 PM revealed that five (5) out of five (5) residents were being changed regularly three (3) to four (4) times a day.

Based on the information gathered during this visit 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: 06/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20240521162029
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: 06/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(continued from LIC 9099)

Regarding the allegation that Staff do not ensure that residents' showering needs are met, it was alleged that residents are not getting showers as scheduled. LPA Shaw Ross' interview with three (3) staff on 05/28/25 and LPA's interview today between 11:30 AM to 1:30 PM with four (4) staff revealed that five (5) out seven (7) staff stated that due to lack of staff, they were unable to perform their duties as they should because each staff was attending to twenty three (23) to twenty six (26) residents during their shift. LPA's record review today between 9:45 AM to 11:30 AM revealed that one (1) caregiver is assigned to each floor at the Assisted Living (AL) section with a current census of forty-five (45) residents at twenty-seven (27) residents on the second floor and eighteen (18) residents on the first floor. LPA Shaw Ross' interview with three (3) residents on 05/28/24 and LPA's interview today with seven (7) residents or more than 10% of current census revealed that four (4) out of ten (10) residents interviewed stated that staff were unable to do their showers on schedule.

Regarding the allegation that Staff do not ensure that residents are provided laundry services, it was alleged that residents were not getting their clothes laundered. LPA Shaw Ross' interview with three (3) staff on 05/28/25 and LPA's interview today between 11:30 AM to 1:30 PM with four (4) staff revealed that five (5) out seven (7) staff stated that due to lack of staff, they were unable to perform their duties as they should because each staff was attending to twenty three (23) to twenty six (26) residents during their shift. LPA's record review today between 9:45 AM to 11:30 AM revealed that one (1) caregiver is assigned to each floor at the Assisted Living (AL) section with a current census of forty-five (45) residents at twenty-seven (27) residents on the second floor and eighteen (18) residents on the first floor. LPA Shaw Ross' interview with three (3) residents on 05/28/24 and LPA's interview today with seven (7) residents or more than 10% of current census revealed that five (5) out of ten (10) residents interviewed stated that staff were unable to do their laundry as scheduled.

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

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20240521162029
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2025
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

This requirement is not met as evidenced by:

Based on LPAs interview with staff and
1
2
3
4
5
6
7
RS Director agreed to inform the Executive Director to come up with the staffing and implementation plan to rectify the staffing issue and submit to CCL on or before the POC date.
8
9
10
11
12
13
14
residents, licenssee did not ensure that the facility has enough staff to perforn care and supervision to residents, this poses an immediate health and safety and personal rights risk to the residents in care.
8
9
10
11
12
13
14
Type A
06/09/2025
Section Cited
CCR
87411(a)
1
2
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6
7
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs......

This requirement is not met as evidenced by:
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2
3
4
5
6
7
RS Director agreed to inform the Executive Director to come up with the staffing and implementation plan to rectify the staffing issue and submit to CCL on or before the POC date.
8
9
10
11
12
13
14
Based on LPAs record review and interviews, licensee did not ensure that the facility has sufficient staffing to provide the necessary services, this poses an immediate health and safety risk to the residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5