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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601134
Report Date: 09/05/2025
Date Signed: 09/05/2025 03:27:48 PM

Document Has Been Signed on 09/05/2025 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SUNRISE AT LA COSTAFACILITY NUMBER:
374601134
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, MARLENFACILITY TYPE:
740
ADDRESS:7020 MANZANITA STTELEPHONE:
(760) 930-0060
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 120CENSUS: 89DATE:
09/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Executive Director Jennifer Ortega TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA), Hannah Rodgers conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Jennifer Ortega.

The facility self-reported an incident that occurred on June 1, 2025, and June 2, 2025, involving Resident #1 (R1), Resident #2 (R2), and Staff #1 (S1) [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The incident report indicated on June 1, 2025, S1 was rough with R1, by grabbing and pulling on both of R1’s wrists in order to get them out of their wheelchair. It was also reported that on June 2, 2025, S1 was witnessed pushing R2’s walker into R2’s knees after R2 would not comply with standing up as S1 had instructed. S1 was placed on suspension and their last day worked was June 2, 2025. S1 was officially terminated by the facility on June 3, 2025.

During today’s visit, LPA briefly toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed staff and residents.

Interviews with internal sources revealed that S1 was seen being rough R1 and R2 primarily during transfers. LPA attempted to interview R1 and R2, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. Review of R1’s physician’s report dated July 26, 2024, and R2’s physician's report dated June 18, 2025, revealed that both R1 and R2 have a primary diagnosis of Alzheimer's Disease, and both require assistance with all Activities of Daily Living (ADLs) except for feeding themselves.

[CONTINUED ON LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Hannah Rodgers
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SUNRISE AT LA COSTA
FACILITY NUMBER: 374601134
VISIT DATE: 09/05/2025
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Review of S1’s Performance Counseling & Improvement Plan for Corrective Action signed and dated June 6, 2025, revealed that S1 did not follow the policy/company rule of abuse or neglect of a resident and was terminated as a result.

One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). An exit interview was conducted with Executive Director Ortega, to whom a copy of this report, LIC 809-C, LIC 809-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Hannah Rodgers
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/05/2025 03:27 PM - It Cannot Be Edited


Created By: Hannah Rodgers On 09/05/2025 at 02:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNRISE AT LA COSTA
FACILITY NUMBER: 374601134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
87468.2(a)(8)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: "(a)...residents... shall have all of the following personal rights: (8) To be free from neglect...punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse." This requirement was not met, as evidenced by:
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Licensee terminated S1's employment on 6/3/2025 as a result of the incidents with R1 and R2. Licensee provided proof of S1's termination. The deficiency was cleared during LPA's visit.
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Based on interview and record review, the licensee did not comply with the section cited above as two (2) out of eighty-nine (89) residents were not free from neglect, punishment, and/or physical abuse by S1, which posed a potential health, safety, and personal rights risk to persons 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Hannah Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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