Sun City Gardens

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff overmedicated resident resulting in hospitalization

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.... Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 24, 2026 · control 18-AS-20250508145059

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff locked residents in their rooms. Facility is in disrepair

The reason for the subsequent visit it to make a correction on the citation and provide additional information not included on the report dated 5/17/25, all other findings remain the same. Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPA met with Brenda Sanchez and explained the reason for the visit. LPA conducted physical plant tour at 11:00 AM, requested copies of facility documents relevant to the investigation at 11:20 AM and interviewed staff and resident between 11:30:00 AM to 2:00 PM. Regarding the allegation that Staff locked residents in their rooms, it was alleged that residents' Memory Care doors were locked from the outside. LPA's physical plant tour today revealed that residents' door at Memory care were locked from the outside even when the resident is inside the room. (continued on LIC 9099-C) Substantiatedthe state’s words, verbatim · CDSS document, Nov 8, 2025 · control 18-AS-20231024121610

Allegation investigated: Staff do not answer residents' call buttons in a timely manner Staff do not ensure that residents' showering needs are met Staff do not ensure that residents are provided laundry service

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit at this facility to investigate the above allegations. LPA met with Resident Services Director (RSD) Brenda Sanchez and explained the reason for the visit. LPA conducted physical plant tour at 9:02 AM, requested copies of facility documents relevant to the investigation at 9:43 AM, reviewed documents between 9:45 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 1:30 PM. Regarding the allegation that Staff do not answer residents' call buttons in a timely manner, it was alleged that residents are not having their call buttons answered for extended periods of time. LPA Shaw Ross' interview with three (3) residents on 05/28/24 and LPA's interview today with seven (7) residents or more than 10% of current census revealed that five (5) out of ten (10) residents interviewed stated that staff comes more than an hour after pressing their call button. Three (3) residents interviewethe state’s words, verbatim · CDSS document, Jun 7, 2025 · control 18-AS-20240521162029

Allegation investigated: Staff did not provide resident with modified diet as prescribed. Staff did not ensure resident’s room was adequately cleaned. Staff did not assist resident with personal hygiene care. Staff did not dispense resident’s medication as prescribed. Staff did not refill resident's medication in a timely manner.

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPA met with Brenda Sanchez and explained reason for the visit. LPA conducted physical plant tour at 8:55 AM, requested copies of facility documents relevant to the investigation at 9:38 AM, reviewed records between 10:00 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 1:30 PM. Regarding the allegation that Staff did not provide resident with modified diet as prescribed, it was alleged that staff not making sure thickened water is available for Resident #1 (R1) to drink because R1 was having trouble swallowing. LPA's record review today revealed that R1 was admitted on 11/22/22 had trouble swallowing and was prescribed to be given honey thick liquid on 01/09/24 by the Hospice Doctor. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that when they were taking cathe state’s words, verbatim · CDSS document, May 18, 2025 · control 18-AS-20240819145843

Allegation investigated: Facility is retaining a resident that requires a higher level of care

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPA met with Brenda Sanchez and explained the reason for the visit. LPA conducted physical plant tour at 8:38 AM, requested copies of facility documents relevant to the investigation at 9:05 AM, reviewed records between 9:15 AM to 10:00 AM and interviewed staff and resident between 10:00 AM to 10:35 AM. Regarding the allegation that Resident #1 (R1) was not capable of making medical and financial decisions independently and R1's memory is declining rapidly. LPA's record review revealed that R1 was admitted at the facility on 11/15/22, declared self-responsible and did not list any family member on record. Further review also revealed that upon admission, R1 had the capacity for self-care and able to do own Activity of Daily Living (ADL)'s aside from minimal assistance on bathing. On 08/04/23, R1 had medication payment issues that the Adult Prothe state’s words, verbatim · CDSS document, May 17, 2025 · control 18-AS-20230814190432

Allegation investigated: Staff locked residents in their rooms. Facility is in disrepair

This report is being amended to rectify typographical error. No change in findings. Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPA met with Brenda Sanchez and explained the reason for the visit. LPA conducted physical plant tour at 11:00 AM, requested copies of facility documents relevant to the investigation at 11:20 AM and interviewed staff and resident between 11:30:00 AM to 2:00 PM. Regarding the allegation that Staff locked residents in their rooms, it was alleged that residents' Memory Care doors were locked from the outside. LPA's physical plant tour today revealed that residents' door at Memory care were locked from the outside even when the resident is inside the room. Regarding the allegation that Facility is in disrepair, it was alleged that Door at Memory Care in Bldg. 200 was broken and wide open 24/7. LPA Goodrich's physical plant tour on 10/31/23 revealed that the door wthe state’s words, verbatim · CDSS document, May 17, 2025 · control 18-AS-20231024121610

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained unexplained injuries while in care

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Georgianna Mendez, Executive Director, who was informed of today's visit. The Department investigation involved interviews with staff and review of records. It was alleged resident sustained unexplained injuries while in care. According to records reviewed by LPA and interviews conducted with staff, it was determined that Resident #1 (R1) was a non-verbal, bedridden and receiving hospice care since 2021. R1 required a two-person assist due to their frail condition. Two (2) current staff members who provided care to R1 during R1’s residency at the facility were interviewed as part of the investigation. Both staff members confirmed that R1’s bedridden condition required a 2-person assist and stated that caregivers at the facility underwent specialized training (repositioning and feeding position) provided by the hospice agency for every residenthe state’s words, verbatim · CDSS document, Apr 29, 2025 · control 18-AS-20240325081849

Allegation investigated: Due to neglect, a resident sustained pressure injuries while in care.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Georgianna Mendez, Executive Director, and informed them the purpose of LPA's visit. The Department investigation involved interviews with staff and review of records. It was alleged that due to neglect, a resident sustained pressure injuries while in care. LPA’s records review revealed the following for Resident #1 (R1). R1 had been admitted to Sun City Gardens on June 10, 2023, and resided there until December 10, 2023. A physician’s report dated July 10, 2023, stated R1 was non-ambulatory and noted a history of skin conditions or skin breakdowns, no further details about R1's skin condition were provided. Facility records included R1’s narrative charting from June 27, 2023, to February 13, 2024. Upon review, LPA found no documentation indicating R1 had sustained pressure injuries. Continued on LIC9099-C.... Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 18-AS-20240213115944

Allegation investigated: Facility staff failed to keep facility free of pests (nats, bed bugs, maggots).

Licensing Program Analsyt (LPA) Alberto Lopez made an unannounced visit to investigate the above allegation. LPA met with Business Manager Barbara Guzman and discussed the purpose of the visit. The investigation consisted of obtaining and reviewing staff and resident rosters, interviewing six (6) staff and eight (8) residents, taking a tour of resident rooms and common areas, Invoice from Orkin Pest control dated 03/26/2025. LPA also obtained and reviewed Orkin Service Reports dated 10/28/2024, 11/01/2024, 11/06/2024, 11/14/2024, 12/04/2024, 12/06/2024, 12/18/2024, 01/17/2025, 01/22/2025, 01/24/2025, 01/29/2025, 02/6/2025, 02/06/2025. The investigation revealed. Allegation: Facility staff failed to keep facility free of pests (nats, bed bugs, maggots). It is alleged that there is an infestation of bedbugs, maggots and nats in some rooms at facility and that facility failed to keep rooms free of pest. (continued on 9099C) Substantiatedthe state’s words, verbatim · CDSS document, Apr 12, 2025 · control 18-AS-20241113130413

Allegation investigated: Staff did not timely replace a light bulb in a resident's room

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation pertaining to the allegation listed above. LPA met with Executive Director Joey Collado and Business Office Manager Barbara Guzman and explained the purpose of the visit. On February 1, 2024, Community Care Licensing received a complaint alleging staff did not replace a light bulb in Resident #1’s bedroom due to an outage and that R1 could not see to get to the restroom. LPA conducted an interview with Administrator which revealed that when services request is presented, maintenance fixes as soon as possible. Administrator also stated that there was no request for a light bulb replacement. Information obtained from interviews with maintenance and housekeeping staff revealed that resident’s room has two lamps with working lightbulbs and the hallway light illuminates the pathway leading to the resident’s restroom from the bathroom. LPA conducted an Interview with an additionathe state’s words, verbatim · CDSS document, Feb 19, 2025 · control 18-AS-20240201095941

Allegation investigated: Wrongful Eviction Staff are retaliating against resident for complaining

Licensing Program Analyst (LPA), Yolanda Delgado made an unannounced visit to the facility to investigate a complaint regarding the allegations listed above. LPA met with Executive Director, Jose (Joey) Collado, Barbara Guzman, Business Office Director and explained the purpose of the visit and the elements of the allegations. LPA Delgado conducted the investigation which consisted of interview with staff members, Resident (R#1) and record review. On January 10, 2025, Community Care Licensing received a complaint stating wrongful eviction and staff are retaliating against resident for complaining. The allegation stated that the resident received a 3-day eviction notice from the facility and the facility is trying to get the resident out due to resident making numerous complaints against the facility. During the LPA’s investigation it revealed that R#1 does not reside in the Assisted Living and does not reside in the Memory Care at the facility. LPA confirmed with R#1 and staff that R#1the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 18-AS-20250110170006

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff did not provide adequate supervision to resident in care.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation noted above. LPA met with Administrator Diane Domingo where LPA explained the purpose of the visit and the elements of the complaint allegation. The allegation was investigated, the investigation consisted of observations, interviews and records review. On 10/14/24 Community Care Licensing received a complaint alleging facility staff did not provide adequate supervision to resident in care. It was alleged that Resident #1 (R1) had eloped multiple times inside the facility and into another building, and had eloped from the facility and was found on the freeway. Additionally, it was alleged that R1 was able to elope due to there not being a security guard on the premises during the night time/NOC hours (10pm-7am). Per an interview with Administrator Diane the incident did in fact occur with R1 eloping and being found on the freeway andthe state’s words, verbatim · CDSS document, Oct 21, 2024 · control 18-AS-20241014123647

Allegation investigated: Facility staff did not dispense medications as prescribed

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Executive Director Diana Domingo and Resident Service Director Bituin Garcia and explained the purpose of the visit. Complaint investigation consisted of a tour of the interior/exterior areas of the facility, interviews, and records review of requested pertinent documents. Regarding the allegation “Facility staff did not dispense medications as prescribed” it was reported Resident One (R1) has not been receiving their medication for months. Interview with Staff One (S1) revealed the facility received a new medication order for R1 that had a change of dosage from 500mg to 200mg and staff had requested clarification of correct dosage for R1’s medication on 06/29/2023. Staff received a medication list from R1’s physician dated 08/28/2023 with R1’s medication with a dosage of 200mg and orders to take orally twice a day. Substantiatedthe state’s words, verbatim · CDSS document, Aug 29, 2024 · control 18-AS-20240515150339

Allegation investigated: Due to neglect, resident sustained pressure injuries/bruises

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation noted above. LPA met with Executive Director Elizabeth "Diane" Domingo and explained the purpose of the visit and the elements of the allegation. On 7/11/24 Community Care Licensing received a complaint alleging due to neglect, resident sustained pressure injuries/bruises. Resident #1 (R1) was admitted to the facility on 7/7/24, upon admission the Resident Services Director Bituin Garcia was conducting a physical assessment and observed R1 to have "weeping" (fluid leaking from their legs) and multiple wounds. R1 was observed to have wounds on both their upper and lower extremities, as well as bruising to upper and lower extremities, and their head drooping to the left side. At approximately 3:31pm emergency medical services was contacted and transported R1 to the hospital due to the condition upon admission. Per an interview with Resthe state’s words, verbatim · CDSS document, Jul 17, 2024 · control 18-AS-20240711084938

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not ensure resident's room was free of rodents Staff are not providing a healthful environment for resident

Licensing Program Analyst (LPA) Sara Martinez made an unannounced visit to initiate the investigation regarding the allegation(s) listed above. LPA was granted entry and met with Executive Director Diane Domingo and explained the purpose of the visit. LPA conducted a tour of the interior/exterior areas of the facility, conducted interviews, and requested copies of pertinent documentation. Interview with Executive Director Domingo revealed Resident One (R1) lives in the independent living units at the facility. Record review of the facility's assisted living and memory care resident roster confirmed R1 lives in the facility's independent living units which is not licensed by the Department and Community Care Licensing (CCL) does not have jurisdiction over the independent living units of the facility. Therefore the allegation(s) listed above has been deemed UNFOUNDED at this time. A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or isthe state’s words, verbatim · CDSS document, May 1, 2024 · control 18-AS-20240423144356

Allegation investigated: Staff did not seek medical attention for resident. Resident was exposed to hazardous gas while in care.

Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to deliver findings for the allegations noted above. LPA met with Barbara Guzman, Business Office Manager and explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews, and records review. On 2/26/2024, Community Care Licensing received an complaint alleging staff did not seek medical attention for a resident, and that resident was exposed to hazardous gas while in care. The LPA conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. LPA was provided with the roster for the facility. A review of the resident roster and face sheet indicted that the resident lives in the independent living section of the facility and that CCLD does not have jurisdiction over the independent living units of the facility. Therefore, this complaint is unfounded.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 18-AS-20240226164235

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.