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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881358
Report Date: 03/24/2026
Date Signed: 03/24/2026 11:04:35 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
05/08/2025 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250508145059
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: 38DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Barbara Guzman, Business Office ManagerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff overmedicated resident resulting in hospitalization
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 Barbara Guzman, Business Office Manager. The Department’s investigation involved interviews with staff, relevant parties and residents and reviews of records.

On 05-08-2025, Community Care Licensing (The Department) received a complaint report with the following allegation.

It was alleged that facility staff overmedicated resident resulting in hospitalization. Information received indicated that Resident #1 (R1) was observed to be unresponsive and overmedicated on 04-27-2025. R1 was transferred to a hospital and was admitted for a left femur fracture on the same day. The Department’s record review revealed that R1 had been under hospice care and was receiving routine pain medication along with as needed (PRN) pain medication of a different type. Continued on LIC9099-C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
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
Control Number 18-AS-20250508145059
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: 03/24/2026
NARRATIVE
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The Department conducted interviews with five (5) staff members, all of whom denied over-medicating R1. All staff members interviewed stated that medication technicians are required to document and sign off after every medication was administered to residents in care, in accordance with physicians’ prescriptions. The Department’s review of medication administration records corroborated the staff members’ statements. The Department obtained and reviewed R1’s medical records. R1’s medical records did not have any diagnosis or assessment of overmedication. The Department attempted to interview R1, but R1 was unable to answer any questions due to their cognitive condition.

Based on interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation. Therefore, the allegation that facility staff overmedicated resident resulting in hospitalization 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: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 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
05/08/2025 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250508145059

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: 38DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Barbara Guzman, Resident Service DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff did not adequately address resident's fall risk resulting in injuries
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 Barbara Guzman, Business Office Manager. The Department’s investigation involved interviews with staff, relevant parties and residents and reviews of records.

On 05-08-2025, Community Care Licensing (The Department) received a complaint report with the following allegation.

It was alleged that facility staff did not adequately address resident’s fall risk resulting in injuries. Information received indicated that Resident #1 (R1) sustained an unwitnessed fall on 04-25-2025, was transported to a hospital, and was diagnosed with left femur fracture.

The Department’s review of R1’s resident file revealed that R1 had diagnosis of cognitive condition, and R1’s fall risk assessment showed level 3 out 3 which was considered as high fall risk. Continued on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20250508145059
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: 03/24/2026
NARRATIVE
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However, R1 resided at an assisted living side of the facility, and R1’s care plan did not include any intervention strategies as it only showed “reminders only” for ambulation and fall risk areas. The Department conducted an interview with resident service director who stated that frequent room checks were done, but R1’s care plan reflected the standard two-hour room checks.

The Department conducted a review of R1’s hospice records which required R1’s hospital bed to be set at the lowest position due to R1’s fall risk. R1 was placed under hospice care starting from April 2024. The Department conducted a tour of the facility and observed that R1’s room contained both a regular queen-size bed and a hospital bed. The Department’s interviews with resident care coordinator and Staff #1 (S1) revealed that R1 had used the regular bed provided by R1’s family, rather than the hospital bed provided by R1’s hospice agency. The former resident service director asked R1’s family to remove the regular bed, but the regular bed was not removed.

The Department conducted interviews with five (5) staff members, all of whom stated that R1 wandered a lot and required frequent redirection as R1 was confused most of the time. Two (2) out of five (5) staff members interviewed stated that they were not aware of R1’s high fall risk status.

Based on the Department’s record review and interviews conducted, the Department determined that R1 required higher level of care than the facility had provided. The Department’s investigation provided enough information to corroborate the allegation that facility staff did not adequately address resident’s fall risk resulting in injuries. This allegation is substantiated.

An immediate civil penalty of $500 is being assessed. In accordance with CCR Code Section 87468.2(a)(4), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was provided, along with LIC9099D, LIC421IM and Appeal Rights.

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

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 18-AS-20250508145059
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: 03/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities, (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(4)To care, supervision, and services that meet their individual needs...
This requirement is not met as evidenced by:
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Licensee agreed to update care plans with change of conditions and every 6 months. Licensee will send copies of current facility policies to LPA by the POC due date via email.
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Based on interviews conducted and records review, Licensee did not provide corresponding level of care that R1 was assessed with. This posed an immediate health and safety risk to residents in care.
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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: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5