374602480-2-14-2026-08-AS-SMAZ-DRTSJR-20260303125535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602480
Report Date: 02/14/2026
Date Signed: 02/14/2026 11:57:01 AM

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
12/13/2021 and conducted by Evaluator Nacole Patterson

COMPLAINT CONTROL NUMBER: 08-AS-20211213093115

FACILITY NAME:	SAGE GARDEN AT RANCHO BERNARDO, THE		FACILITY NUMBER:	374602480
ADMINISTRATOR:	MARIA RINA CHANG		FACILITY TYPE:	740
ADDRESS:	12295 FRONTERA RD		TELEPHONE:	(858) 716-3947
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	6	CENSUS: 6	DATE:	02/14/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Licensee Rina Chang		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff failed to provide medical treatment for pressure injuries
Residents sustained unexplained injuries while in care
Lack of supervision resulting in residents falling
Staff yells at residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted a virtural visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Licensee Rina Chang.

On 12/13/2021 it was alleged that staff failed to provide medical treatment for pressure injuries, residents sustained unexplained injuries while in care, lack of supervision resulted in residents falling, and staff yelled at residents. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Staff interviews did not corroborate the allegation, as staff denied observing other staff yell at residents. Staff informed that while a resident did suffer a skin tear and bruise, the incidents were explained and not caused by staff. Staff interviews additionally revealed that two residents were on Hospice where minor pressure-related skin conditions were common due to the nature of palliative care and hospice resident immobility.
(Continued on LIC9099 p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2026

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-20211213093115

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: SAGE GARDEN AT RANCHO BERNARDO, THE	FACILITY NUMBER: 374602480
	VISIT DATE: 02/14/2026

NARRATIVE

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(Continued from LIC9099 p.1)

Staff refuted that residents were unsupervised at night, as claimed, informing that night staff remain awake during their shift to respond to resident care needs.

Outside source interviews corroborated staff statements regarding residents on hospice care at the facility. Outside source interviews did not corroborate the allegations, as outside sources had not observed staff treating residents without dignity or neglecting their care. Outside sources stated that staff communicated resident needs and provided great care.

Review of relevant records did not give evidence to the allegations. No records were found to show that residents suffered unexplained injuries or falls. Records corroborated staff statements regarding specific residents being on hospice care, and having pre-existing skin issues.

During an unannounced facility visit, the investigating LPA directly observed all residents in the facility for evidence of the allegations and conducted a health and safety check. The LPA did not observe any unexplained injuries during the visual check of residents.

Due to impaired cognition, resident interviews were not able to be conducted due to inability to verify residents as valid historians.

The evidence found does not support the allegations and shows that resident co-morbidities, behavioral and medical conditions contributed to the pressure injuries, bruises, and scratches. Evidence showed that some injuries/bruises existed prior to the resident moving into the facility. Due to lack of specifics regarding which allegations pertained to specific residents, correlation of abuse was not able to determined, if any. Resident records were consistent with staff statements regarding resident care. No evidence was found to show that staff did not provide the care required for each resident in their needs & services plans. Records also showed that all five residents were being followed by either Hospice or Home Health. Evidence was not found to show that staff did not communicate care needs for any resident. Staff and outside source interviews did not corroborate the claim that staff yelled at residents.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Licensee Rina Chang, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2026

LIC9099 (FAS) - (06/04)

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