374604388-4-22-2026-08-AS-APAO-DTLR32-20260429123912

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604388
Report Date: 04/22/2026
Date Signed: 04/22/2026 09:53:21 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
07/16/2024 and conducted by Evaluator Janet Ngallo

COMPLAINT CONTROL NUMBER: 08-AS-20240716154743

FACILITY NAME:	SUNSET CLIFFS ELDER CARE		FACILITY NUMBER:	374604388
ADMINISTRATOR:	TRAVONNA WASHINGTON		FACILITY TYPE:	740
ADDRESS:	1039 SANTA BARBARA STREET		TELEPHONE:	(619) 791-5495
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92107
CAPACITY:	6	CENSUS: 6	DATE:	04/22/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Nikki Mundhada		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Unqualified staff are providing wound care to a resident in care.
Licensee retained a resident with a prohibited condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Janet Ngallo conducted a telephone visit to conclude and deliver findings regarding the above mentioned allegations. LPA discussed the complaint with Nikki Mundhada.

On 07/16/2024, it was alleged that unqualified staff provided wound care to a resident in care and that the Licensee retained a resident with a prohibited condition. The department's investigation consisted of unannounced facility visits, interviews, and records review.

Regarding the allegation that unqualified staff provided wound care, interviews reported only replacing a dressing when it became wet or loose, as directed by the resident’s outside care team, while licensed professionals from hospice or the care team were responsible for actual wound care.

Records review of R1's hospice care plan initiated on 07/17/2024 revealed that hospice is to perform wound care 3 times a week. (Cont. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

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-20240716154743

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: SUNSET CLIFFS ELDER CARE	FACILITY NUMBER: 374604388
	VISIT DATE: 04/22/2026

NARRATIVE

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(Cont. from LIC 9099)

Regarding the allegation that the licensee retained a resident(R1) with a prohibited condition, interviews revealed that R1 arrived unexpectedly during the evening of 07/15/2024 with multiple wounds, and facility staff immediately contacted the on-call nurse and the discharging social worker to clarify expectations for care. Interviews with R1's outside care team stated that the hospital discharged R1 prematurely, due to hospital practices to discharge within a three-day window or as soon as medically stable, even when a resident requires a higher level of care. Interviews with R1's care team further revealed that the hospital recommended that R1 go back to assisted living under hospice services or skilled nursing facility, however R1's responsible parties declined and requested that the resident return to the facility. Interviews revealed that upon the resident’s arrival, facility staff immediately contacted the care team and sought guidance. The resident was subsequently enrolled in hospice, and skilled wound care was assigned to outside licensed providers.

Records revealed that R1 was discharged from the hospital on 07/15/2024 and hospice did not begin providing oversight until the evening of 07/17/2024. Records review of email correspondence from the facility administrator on the evening of 07/15/2024 showed immediate communication with R1's care team, documenting R1’s arrival condition, the discovery of an unstageable wound, and coordination to determine how often the care team or home-health nurses could visit to address wound care. Additional email correspondence from the next morning, 07/16/2024, summarized the Administrator’s call with the care team, clarifying that the facility had not been informed of the discharge, had refused to accept the resident until receiving a revised 602, and reiterated that the facility could not provide skilled wound care and would follow R1's care team and hospice directives. The Administrator emphasized collaboration with the care team and expressed full support for placement in a skilled nursing facility if the care team determined it was appropriate.

Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. An exit interview was conducted with Administrator Nikki Mundhada and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided via email.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

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