374601134-12-17-2025-08-AS-JROO-DQ94EK-20260111180224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601134
Report Date: 12/17/2025
Date Signed: 12/17/2025 02:23:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2022 and conducted by Evaluator Becky Kennedy

COMPLAINT CONTROL NUMBER: 08-AS-20221005150217

FACILITY NAME:	SUNRISE AT LA COSTA		FACILITY NUMBER:	374601134
ADMINISTRATOR:	LAVENDER, WESLEY D		FACILITY TYPE:	740
ADDRESS:	7020 MANZANITA ST		TELEPHONE:	(760) 930-0060
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	120	CENSUS: 86	DATE:	12/17/2025
		UNANNOUNCED	TIME BEGAN:	02:04 PM
MET WITH:	Jennifer Ortega		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Staff obtained outside services for the resident without prior authorization
Staff did not properly supervise the resident
Staff did not get resident appraisal updated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint visit to the facility to deliver findings on the above allegations. LPA was granted entry to the facility after identifying herself. LPA met with Jennifer Ortega, Executive Director and explained the purpose of the visit

The Department’s investigation consisted of review of facility records, outside source records, and interviews of facility staff and outside sources.

The allegations in this complaint all involve Resident 1 (R1).
The investigation revealed R1’s mental wellbeing was of some concern prior to admission, including a period of psychiatric hospitalization about a month prior to admission. The initial assessment for R1 noted a mood of sadness and the facility staff would encourage R1 to express their feelings and concerns during mood changes

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20221005150217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/17/2025

NARRATIVE

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R1’s physician’s report noted R1 was depressed but was not suicidal. The physician determined that R1 could leave the facility without supervision.

About five months after admission R1 was overheard talking with a suicide prevention hotline. The facility staff contacted R1’s responsible party who was unavailable to assist in obtaining an assessment of R1's needs. The facility contacted the Psychiatric Emergency Response Team (PERT), and after the PERT assessment R1 was transported to a hospital for evaluation. Two days after the PERT assessment the resident was released from the hospital without being admitted for in-patient psychiatric services. The discharge documentation had a note signed by the physician stating R1 “is not suicidal”.

Twenty-five days later R! was brought into the facility accompanied by an outside individual who reported that R1 was walking into traffic.

The following day facility staff conducted a Suicide Risk Assessment regarding R1. Although R1 denied being suicidal, or having a plan, R1’s behavior of walking in the street without an apparent concern for their safety was noted.

After the assessment, and noting the very concerning behavior, facility staff determined that a one-to-one companion was needed to keep R1 safe. An email was sent on a Monday to inform R1’s responsible party of the requirement for a one-to-one companion. Facility staff told R1’s responsible party that they had until Friday to hire a companion. On Wednesday facility staff hired a companion. Interviews revealed that the facility’s practice would be to use facility staff as one-to-one companions until outside staff could be secured. R1 is responsible for the cost of these services.

It was alleged that facility staff obtained outside services for the resident without prior authorization.
Residential Care Facilities for the Elderly (RCFE) are required to follow Title 22, Division 6 Chapter 8 regulations. Section 87466-Observation of the Resident states that “the licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.”

SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20221005150217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/17/2025

NARRATIVE

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A review of the admission agreement signed by R1’s responsible party states that “the community will revaluate resident’s needs to determine which service level is appropriate... The fee charged will be based upon the Service Level provided.”

The community determined that R1 needed additional services and arranged for those serviced to be provided. Not the admission agreement, nor the RCFE regulations require that prior authorization is required. This allegation is Unsubstantiated.

It was further alleged that facility staff did not properly supervise the resident.

The investigation revealed that R1’s initial physician’s report stated that R1 could leave the facility without supervision. Until the incident when R1 was found to be acting unsafe in traffic, the facility had no reason to supervise R1 outside of the community. This allegation is Unsubstantiated.

It was further alleged that facility staff did not get resident appraisal updated.

The investigation revealed that the day after the incident where R1 was unsafe in traffic, a Suicide Risk Assessment was completed to address the area of concern regarding R1. This allegation is Unsubstantiated.

Based on the evidence obtained during the complaint investigation, the above allegations are UNSUBSTANTIATED, meaning the preponderance of evidence standard was not met to prove a violation occurred.

An exit interview was conducted with Jennifer Ortega, Executive Director; a copy of this report and Licensee's Rights (LIC9058) were provided.

SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025

LIC9099 (FAS) - (06/04)

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