Sun City Gardens

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Resident sustained bites and rash due to staff neglect or physical abuse Staff do not ensure facility is free of insects

On July 16, 2026, at approximately 9:20 a.m., Licensing Program Analyst (LPA) Toni Nwala conducted an unannounced visit to the facility to initiate the investigation into the allegations listed above. The LPA met with Patricia Russell, Executive Director, and informed her of the purpose of the visit. The LPA conducted a review of facility records and requested copies of pertinent documentation. During the visit, the LPA did not observe any health or safety concerns.Based on the record review, the allegations that a resident sustained bites and a rash due to staff neglect or physical abuse, and that staff failed to ensure the facility was free of insects, are determined to be unfounded. The investigation confirmed that Resident 1 (R1) is not associated with the licensed facility, as R1 resides in the independent living section of the campus, which is not part of the licensed residential care facility. A finding that a complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was explained and emailed to the ED, Patricia Russell. Unfoundedthe state’s words, verbatim · CDSS document, Jul 16, 2026 · control 18-AS-20260706144125

Type of visit: Case Management - Other

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Executive Director Patricia Russell ,informed her of the purpose of the visit and was granted access. Community Care Licensing (CCL) received a SOC 341 from the facility indicating an alleged physical abuse by Staff 1(S1) toward resident 1 (R1). LPA's case management included interview with staff , obtaining pertinent documentation and conducting a tour of the facility for a health and safety check. No immediate health and safety concerns were observed during today's visit. Executive Director Patricia Russell informed LPA that an internal investigation was conducted and S1 was terminated. Executive Director Patricia was advised that possible visits and phone interviews will be conducted before a decision is rendered. An exit interview was conducted and a copy of this report was provided to Executivethe state’s words, verbatim · CDSS document, May 21, 2026

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.... Unsubstantiated The Department conducted interviews with five (5) staff members, all of whom denied over-medicating R1. All staff members interviewed stated that medication technicians are required to document and sign off after every medication was administered to residents in care, in accordance with physicians’ prescriptions. The Department’s review of medication administration records corroborated the staff members’ statements. The Department obtained and reviewed R1’s medical records. R1’s medical records did not have any diagnosis or assessment of overmedication. The Department attempted to interview R1, but R1 was unable to answer any questions due to their cognitive condition. Based on interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation. Therefore, the allegation that facility staff overmedicated resident resulting in hospitalization is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided. However, R1 resided at an assisted living side of the facility, and R1’s care plan did not include any intervention strategies as it only showed “reminders only” for ambulation and fall risk areas. The Department conducted an interview with resident service director who stated that frequent room checks were done, but R1’s care plan reflected the standard two-hour room checks. The Department conducted a review of R1’s hospice records which required R1’s hospital bed to be set at the lowest position due to R1’s fall risk. R1 was placed under hospice care starting from April 2024. The Department conducted a tour of the facility and observed that R1’s room contained both a regular queen-size bed and a hospital bed. The Department’s interviews with resident care coordinator and Staff #1 (S1) revealed that R1 had used the regular bed provided by R1’s family, rather than the hospital bed provided by R1’s hospice agency. The former resident service director asked R1’s family to remove the regular bed, but the regular bed was not removed. The Department conducted interviews with five (5) staff members, all of whom stated that R1 wandered a lot and required frequent redirection as R1 was confused most of the time. Two (2) out of five (5) staff members interviewed stated that they were not aware of R1’s high fall risk status. Based on the Department’s record review and interviews conducted, the Department determined that R1 required higher level of care than the facility had provided. The Department’s investigation provided enough information to corroborate the allegation that facility staff did not adequately address resident’s fall risk resulting in injuries. This allegation is substantiated. An immediate civil penalty of $500 is being assessed. In accordance with CCR Code Section 87468.2(a)(4), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided, along with LIC9099D, LIC421IM and Appeal Rights.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 18-AS-20250508145059

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 31, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities, (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(4)To care, supervision, and services that meet their individual needs... This requirement is not met as evidenced by: Based on interviews conducted and records review, Licensee did not provide corresponding level of care that R1 was assessed with. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Licensee agreed to update care plans with change of conditions and every 6 months. Licensee will send copies of current facility policies to LPA by the POC due date via email.

Type of visit: Required - 1 Year

On 02/11/2026, Licensing Program Analysts (LPAs) Jacqueline Shaw Ross and Venus Mixon, made an unannounced visit to the facility to conduct an annual review. LPAs were greeted by facility staff and granted entry. Executive Director Patricia Russell arrived shortly, and the purpose of the visit was explained. A tour of the facility was conducted inside and out. Resident record review began- A total of six (6) client records were reviewed that included admission agreements, medical assessments and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPAs toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature was logged and tested within regulations. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in a closet. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPAs verified there is a telephone working at this location. Food Service- Food supply was observed and meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. Review of Employee Records- LPAs reviewed employee records that included employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification. CPR and requirements have been met. Cont'd on LIC 809C.... The facility employs an appropriate number of staff to maintain cleanliness and meet the needs of the clients in care. The Administrator's certification is current. LPAs made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested annually and were replaced on 02/05/2026. The facility is conducting emergency disaster drills and met regulations and was logged. The last disaster drill was conducted on 02/05/2026. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted and a copy of this report was provided to Executive Director, Patricia Russell.the state’s words, verbatim · CDSS document, Feb 11, 2026

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) Substantiated (continued from LIC 9099) 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 was broken and had been broken for a while during LPA's visit. LPA Goodrich's interview with three (3) other staff also confirmed that the door was broken but they are trying to fix it. Based on the information gathered during this and prior visit, these allegation are deemed substantiated at this time. Citation issued. Appeal rights explained and given. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Nov 8, 2025 · control 18-AS-20231024121610

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: May 19, 2025

(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by: Based on LPAs observation, memory care residents' door were locked even if the resident is inside. This poses an immediately health and safety and personal rights risk to the residents in carethe state’s words, verbatim · CDSS document, Nov 8, 2025

Plan of correction: RSD will inform the management to remove the lock of the door at the memory care unit and will submit statement of understanding of the above cited regulation and submit proof of removal and statement to CCL on/or before the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: May 17, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA observation the licensee did not ensure that the door of Memory care was in good repair. This poses a potential health and safety risk to the residents in carethe state’s words, verbatim · CDSS document, Nov 8, 2025

Plan of correction: LPA observed during visit the door is repaired and in good condition. Cleared during visit.

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 interviewed stated that they have not used the call button at all. Only two (2) residents interviewed stated that staff come on time within thirty (30) minutes. (continued on LIC 9099-C) Substantiated (continued from LIC 9099-A) Regarding the allegation that Staff spoke inappropriately to resident, it was alleged that S1 threatened Resident #1 (R1). LPA's interview with four (4) staff today revealed that R1's first language was not English and could be misconstrued as aggressive but that was S1's normal voice. Four (4) out of four (4) staff interviewed stated that they did not witness R1 threatening or spoke inappropriately to any resident. LPA's interview with seven (7) residents or more than 10% of current census revealed that seven (7) out of seven (7) residents did not experience or witness R1 threatening any resident. Regarding the allegation that Staff do not ensure that residents are hydrated, it was alleged that Resident #1 (R1) was screaming and needed water. LPA's record review revealed that R1 was admitted at the facility on 04/10/24 and passed away on 05/24/24. LPA's interview with four (4) staff today revealed that they always make sure that all residents have access to and provide drinking water to all residents. LPA's interview with seven (7) residents today or more than 10% of the current census revealed that seven (7) out of seven (7) residents stated that they do not have issues with drinking water and were provided by the staff all the time. Regarding the allegation that Staff did not ensure that residents' incontinence needs were met, it was alleged that R1 was screaming due to being soaked wet for a long period of time. LPA attempted to interview the staff that may have witnessed the incident but the staff no longer works here. LPA's interview with five (5) incontinent residents today between 11:30 AM to 1:30 PM revealed that five (5) out of five (5) residents were being changed regularly three (3) to four (4) times a day. Based on the information gathered during this visit and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued. (continued from LIC 9099) Regarding the allegation that Staff do not ensure that residents' showering needs are met, it was alleged that residents are not getting showers as scheduled. LPA Shaw Ross' interview with three (3) staff on 05/28/25 and LPA's interview today between 11:30 AM to 1:30 PM with four (4) staff revealed that five (5) out seven (7) staff stated that due to lack of staff, they were unable to perform their duties as they should because each staff was attending to twenty three (23) to twenty six (26) residents during their shift. LPA's record review today between 9:45 AM to 11:30 AM revealed that one (1) caregiver is assigned to each floor at the Assisted Living (AL) section with a current census of forty-five (45) residents at twenty-seven (27) residents on the second floor and eighteen (18) residents on the first floor. 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 four (4) out of ten (10) residents interviewed stated that staff were unable to do their showers on schedule. Regarding the allegation that Staff do not ensure that residents are provided laundry services, it was alleged that residents were not getting their clothes laundered. LPA Shaw Ross' interview with three (3) staff on 05/28/25 and LPA's interview today between 11:30 AM to 1:30 PM with four (4) staff revealed that five (5) out seven (7) staff stated that due to lack of staff, they were unable to perform their duties as they should because each staff was attending to twenty three (23) to twenty six (26) residents during their shift. LPA's record review today between 9:45 AM to 11:30 AM revealed that one (1) caregiver is assigned to each floor at the Assisted Living (AL) section with a current census of forty-five (45) residents at twenty-seven (27) residents on the second floor and eighteen (18) residents on the first floor. 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 were unable to do their laundry as scheduled. Based on the information gathered during this and prior visit, these allegations are deemed substantiated at this time. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jun 7, 2025 · control 18-AS-20240521162029

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 9, 2025

Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on LPAs interview with staff and residents, licenssee did not ensure that the facility has enough staff to perforn care and supervision to residents, this poses an immediate health and safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 7, 2025

Plan of correction: RS Director agreed to inform the Executive Director to come up with the staffing and implementation plan to rectify the staffing issue and submit to CCL on or before the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 9, 2025

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...... This requirement is not met as evidenced by: Based on LPAs record review and interviews, licensee did not ensure that the facility has sufficient staffing to provide the necessary services, this poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 7, 2025

Plan of correction: RS Director agreed to inform the Executive Director to come up with the staffing and implementation plan to rectify the staffing issue and submit to CCL on or before the POC date.

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 care of R1 and received the order, they gave R1 thickened water and orange juice regularly every day and even leave a thickened liquid on R1's room. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that Staff did not ensure resident’s room was adequately cleaned, it was alleged that R1's room had urine multiple urine stains. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that they regularly do a light cleaning on everyone's room and the housekeeper do general cleaning of everyone's room once a week. LPA's interview with housekeeping staff yesterday 05/17/25, revealed that they shampoo R1's room whenever requested by the former Resident Service Director (RSD) but denied that it had urine stains. LPA's interview with six (6) Assisted Living (AL) residents revealed six (6) out of six (6) residents state that their room are being cleaned regularly by staff and do general cleaning once a week. Regarding the allegation that Staff did not assist resident with personal hygiene care, it was alleged that staff did not make sure that R1's hands were clean and did not file R1's nails and staff also did not wash R1's face or help brush R1's teeth. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that during their shift (AM) they regularly assist R1 getting up to bed, clean, brush teeth, shower during schedule days and dress and groom before breakfast every day. They stated however that cutting and filing nails were not part of their duty as it may hurt R1 so they had to bring R1 to a podiatrist or a salon. Further, when R1 was admitted to Hospice care, the hospice staff were doing R1's bathing and grooming, including but not limited to nail trimming and filing, shaving, etc., LPA’s record review of hospice notes confirmed that the hospice staff were assisting on R1's ADLs. Regarding the allegation that Staff did not dispense resident’s medication as prescribed, it was alleged that R1 was being over medicated because staff were dispensing medications as directed by an old doctor’s order and not the newest order. LPA's record review revealed that since R1 started on Hospice services, it was the hospice staff checking and reconciling R1's medication and due to R1's condition medication orders changed faster than usual. Further review revealed that all the medications administered to R1 from the period August 2024 up to the time of R1's passing on October 2024 were given as prescribed. (continued on LIC 9099-C-2) (continued from LIC 9099-C) Regarding the allegation that Staff did not refill resident's medication in a timely manner, it was alleged that R1 ran out of heart medication but staff did not inform RP until one week later. LPA's record review revealed that R1 was using facility non-contracted pharmacy, in which the family member and/or responsible party are the ones responsible for contacting the pharmacy for refills. Further review also revealed that R1 did not miss any regularly prescribed medication from July 2024 until the time of R1's passing on October 2024. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the 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 Protective Services (APS) were called to get involved to settle the payment and that R1 needed to have a social worker and Power of Attorney (POA) to handle R1's financial and medical affairs. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA Goodrich's interview with former Resident Care Director (RSD) on 08/22/23 and Executive Director on 09/11/23 revealed that they have contacted and worked with APS and other agency to have R1 appointed a Public Guardian but nothing happened. The facility contacted and located R1's family member and eventually had a family member as a responsible party for medical and financial matters for R1 on 01/18/2024. During this visit, LPA observed that R1 now resides at the facility's memory care unit and observed to be neat, clean and stated that staff are taking good care of R1. Further review also revealed that on 05/21/24, R1 was appointed a temporary public guardian from Riverside County Public Guardian office by the Superior Court of California, County of Riverside Based on the information gathered during this and prior visit, there is insufficient evidence to prove the allegation and therefore deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the 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 was broken and had been broken for a while during LPA's visit. LPA Goodrich's interview with three (3) other staff also confirmed that the door was broken but they are trying to fix it. (continued on LIC 9099-C) Substantiated (continued from LIC 9099-C) Regarding the allegation that Staff do not provide residents needed assistance to keep them safe, it was alleged that staff are not assisting residents going outside and at risk of escaping or getting injured by a car. LPA Goodrich's interview with former Resident Care Director (RSD) on 10/31/23 revealed that those resident wandering outside the building were independent and able to leave the facility unassisted and did not need any assistance. LPA's interview with six (6) Assisted Living (AL) residents or 10% of current census revealed that six (6) out of six (6) residents interviewed stated that they do not need staff assistance going out and being safe at the facility. Regarding the allegation that Staff do not effectively communicate with residents, it was alleged that staff refused and uncommunicative with residents. LPA's interview with six (6) Assisted Living (AL) residents or 10% of current census revealed that six (6) out of six (6) residents interviewed stated that staff are always helpful, respectful and communicate well with them. Regarding the allegation that Staff do not ensure safe keeping of resident's belongings, it was alleged that Residents belongings were stolen by another resident. LPA Goodrich interview with two (2) staff on 10/31/23 revealed that one of the residents reported missing personal belongings were found on own room and recovered all the missing items. LPA's interview with six (6) Assisted Living (AL) residents or 10% of current census revealed that six (6) out of six (6) residents interviewed stated that no one among them had any missing personal belongings or did not witness any resident stealing from any resident. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued. (continued from LIC 9099) Based on the information gathered during this and prior visit, these allegation are deemed substantiated at this time. Citation issued. Appeal rights explained and given. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 17, 2025 · control 18-AS-20231024121610

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(6) · Plan of correction due date: May 19, 2025

(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by: Based on LPAs observation, memory care residents' door were locked even if the resident is inside. This poses an immediately health and safety and personal rights risk to the residents in carethe state’s words, verbatim · CDSS document, May 17, 2025

Plan of correction: RSD will inform the management to remove the lock of the door at the memory care unit and will submit statement of understanding of the above cited regulation and submit proof of removal and statement to CCL on/or before the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 17, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA observation the licensee did not ensure that the door of Memory care was in good repair. This poses a potential health and safety risk to the residents in carethe state’s words, verbatim · CDSS document, May 17, 2025

Plan of correction: LPA observed during visit the door is repaired and in good condition. Cleared during visit.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Yolanda Delgado is conducting an unannounced case management visit on this date to check on the health, safety, and welfare of clients in care. LPA learned that forty-four (44) clients reside in Assisted Living and fifteen (15) clients reside in Memory Care at this facility. There are seven (7) staff on duty currently for the areas. During this visit LPA obtained information through interviews, facility staff are providing care outside of their scope. LPA conducted interviews with individuals who had knowledge of this information. In addition, LPA toured the facility and found no immediate H&S concerns present during today’s visit. Based on the information obtained today, one (1) deficiency is being issued per Title 22, Division 6, Chapter 8, Article 11, Section 87629(a)(1) of the California Code of Regulations. This report, LIC809D and Appeal Rights was reviewed with Georgianna Mendez, and copy provided at the time of exit.the state’s words, verbatim · CDSS document, Apr 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87629(a)(1) · Plan of correction due date: May 1, 2025

87629 INJECTIONS: (a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. (1) Ensuring that injections are met as evidenced by: LPA received report(s) Med Techs were administering insulin injections to three (3) residents and do not maintain a skilled professional license. This poses a potential health and safety risk to the clients in care.the state’s words, verbatim · CDSS document, Apr 30, 2025

Plan of correction: Administrator immediately ceased the practice by Med Techs upon learning and informed resident's responsible parties. Administrator has conducted staff trainings regarding Medication administration aligned with Title 22 as Plan of Correction.

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 resident entering hospice care. However, neither staff member was able to provide an explanation for the bruising observed on R1. Continued on LIC9099-C..... Unsubstantiated The LPA reviewed hospice notes dated from September 29, 2023, to February 27, 2024, and found that hospice nurses consistently educated caregivers and medical technicians during each visit to the facility. The topics covered included repositioning techniques, aspiration precautions, and R1's feeding position. LPA interviewed two (2) hospice nurses who observed R1’s bruises. Both nurses confirmed the bruises were likely from someone’s hand, but neither nurse was able to tell what or who caused the bruises. Both nurses asked the facility caregivers about R1’s bruises at the time of the discovery, but none of the caregivers had any knowledge of events or incidents that could explain R1’s bruises. Based on LPA’s record reviews and staff interviews, the investigation did not reveal corroborating evidence to determine the cause or source of R1’s bruises. Therefore, the allegation is determined to be Unsubstantiated. A finding of Unsubstantiated indicates that while the allegation may have occurred or been valid, there is not a preponderance of evidence to conclusively prove that the alleged violation took place. An exit interview was conducted where a copy of this report was provided.the 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.... Unsubstantiated On December 10, 2023, R1 was sent to the hospital due to an urgent health condition and did not return to the facility afterward. According to records, R1 remained at a skilled nursing facility until March 15, 2024. A Resident Move Out form dated April 24, 2024, confirmed R1 never returned to Sun City Gardens and officially moved out on May 2, 2024. Interviews with two staff members who provided care to R1 revealed R1 was non-ambulatory and R1 was able to stand up and walk. In addition, a Pre-placement appraisal dated June 7, 2023, indicated R1 required use of a walker and or wheelchair. Staff frequently reminded R1 to use a wheelchair due to R1’s tendency to move around without it, but neither staff member recalled R1 having pressure injuries during their time at the facility. Information obtained during this investigation did not corroborate the alleged allegation of R1 sustaining pressure injuries while in care. Based on record reviews and staff interviews, this allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the 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) Substantiated (continued from 9099) LPA interviewed six (6) staff and four (4) of six (6) staff stated they were aware of the pest issue and those staff stated that the facility has addressed the pest issue since. LPA interviewed eight (8) residents and five (5) of eight (8) residents were able to corroborate the allegations. LPA took tour of common areas in building 100, 200, and 300 and rooms 251, 252, 253, 255, 270, 275, 278, 134, 119 and 381. During the tour of the rooms, LPA observed and took pictures of dead bed bugs or insects in the base boards in the closets of room 251 and room 275. LPA did not observed any living bedbugs, insects, mice or other pests in any other rooms or areas inspected by LPA The facility has ongoing contract with Orkin Pest control and LPA reviewed and obtained copies of service reports dated 10/28/2024 (treatment of bed bugs room 251), 11/01/2024 (treatment of bedbugs room 251),11/06/2024 (inspection of room 251 (treatment for mice upstairs building 200 and 300), 11/14/2024 (treatment for mice, rooms 251, 275 for bedbugs), 12/04/2024 (inspection for bed bugs, rooms 251, 272), 12/18/2024 (treatment for bedbugs, rooms 251, 252, 255) 01/17/2025 (treated room 251 for bed bugs-found no living ones), 1/29/2025 (Inspection only), 01/22/2025 (follow-up treatment for bed bugs, rooms 251,253, 255, 314,316, 381, 385, 387, 389, 388, 378, 339, 333, 328, 312, 310, 308), 01/24/2025 (inspection, removal of trapped mice and recommendations) 02/06/2024 (K9 inspection of rooms 251, 252, 253, 254. Live activity found in units 252, 253, 254), 02/28/2025 (first day of heat treatment for bed bugs and termites for rooms 251, 252, 253, 255, 254, 256 and the lower 6 units under those on second day of treatment), 03/26/2025 (invoice for termite heat). The treatment is ongoing and facility will be required to provide proof that the all the pest have been eradicated from the entire facility. There is sufficient evidence to support the allegation. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to Business Manager Barbara Guzman.the state’s words, verbatim · CDSS document, Apr 12, 2025 · control 18-AS-20241113130413

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 26, 2025

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by LPA observed room 251 had dead bedbugs inside the closet by the baseboards and room 275 had evidence of dead insects behind the drawer and by the closet doors. Some residents corroborated the allegation and staff stated they have been addressing the pest issue which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 12, 2025

Plan of correction: Facility must provide proof from Orkin pest control that facility has eradicated all pest including but not limited to bed bugs, nats, maggots. Proof of correction can be sent to LPA by POC date of 04/26/2025

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 additional witness and advised that a family member replaced the lightbulb. (Continued on Page 2) Unsubstantiated (Continued from Page 1) It was not advised if Resident #1 notified staff that a replacement was needed. LPA attempted to interview R#1, but due to R1’s cognitive ability, LPA was unable to verify resident was a reliable historian of record. During a visit to the facility, LPA observed a bedside lamp that was unplugged. The lamp was plugged in and had a working light bulb. LPA checked the other light sources, and they were all in working condition. LPA conducted a review of service requests and there were no requests to replace a light bulb in the resident’s room. Documentation did state that Resident #1 will often unplug their personal lamp and housekeeping will plug the lamp back in. Based on interviews and facility records, the allegation that staff did not replace a light bulb in a resident’s room is Unsubstantiated. Although the allegation may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Joey Collado, ED and a copy of this report along with LIC811- Confidential Names list was provided.the 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#1 resides in the independent living area that is not under the jurisdiction of CCLD. (Continued on Page 2) Unfounded (Continued from Page 1) During the LPA’s interview with Executive Director and Business Office Director, it was concluded that R#1 has never been a resident in the Assisted Living and Memory Care, R#1 is an Independent Living resident. Based on LPA's observations, records review, and staff interview, this agency has investigated the complaint alleging “wrongful eviction” and "staff are retaliating against resident for complaining" we have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to facility representative.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 18-AS-20250110170006

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility with LPA identification and business card. Resident record review began- Six (6) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 112.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in a closet. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA began review of employee records- Seven (7) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification. CPR and requirements have been met. (Continued on next page) (Continued from Page 1) The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification has been renewed, expired in November 2024 and is pending in the database. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 03/24/2024. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 12/15/2024. Resident bedrooms flooring, bathrooms and common areas are being renovated; there was construction observed. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative at the time of the exit interview. *LPA was away from the facility from 12:15-1:15 PM.the state’s words, verbatim · CDSS document, Jan 16, 2025

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 and being brought back by law enforcement on 10/3/24. Diane also stated that the facility did not have a security guard but did have a night time Concierge and that as of 10/01/24, the hours were decreased for the position, resulting in there no longer being Unfounded someone up front but if assistance was needed a call would need to be made and the 24/7 staff inside the back building would assist. LPA conducted a records review of the rent roll and facility census, that revealed R1 resides in the independent building. The department does not have jurisdiction over the independent living units of the facility. Therefore the allegation of facility staff did not provide adequate supervision to resident in care is UNFOUNDED at this time. A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. A exit interview was conducted and a copy of this report along with LIC811 - confidential names list was provided to Diane Domingo, Administrator.the 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. Substantiated Records review of R1’s MAR revealed a note entered by Staff Two (S2) for R1’s medication with instructions “TAKE 1 CAPSULE BY MOUTH TWICE DAILY **NEED TO CLARIFY ORDER – IS WRITTEN AS 200MG” with a Start Date set at 09/08/2023 with an End Date 09/08/2023. Records review of R1’s Medication Administrator Record (MAR) revealed on 10/13/2023 staff stopped administering the medication with a 500mg dosage to R1 with a written in note “Change of Order”. Records review of R1’s MAR after 10/13/2023 did not have R1’s prescribed medication with a dosage of 200 mg with orders to take twice daily. Interview with Staff Three (S3) revealed staff will only give mediation that is listed on the MAR and the prescribed medication was not given to R1. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to Garcia,the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 18-AS-20240515150339

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 13, 2024

87465 Incidental Medical and Dental Care: (a) ... shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with resident one (R1). Medications for R1 were not administered as prescribed. This is a potential health and safety risk for R1 and other residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Licensee implemented a plan to conduct weekly medication audits for the residents in care. Licensee will communicate with Yorba Linda Pharmacy to conduct quarterly audits of the residents medication. Licensee will send LPA confirmation of weekly audit by Plan of Correction date 09/13/2024.

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 Resident Services Director there was a preadmission interview that was conducted via Facetime on 7/2/24 due to the distance of R1's previous residence and the facility. However no wounds were observed. R1 returned to facility on 7/15/24 and is Unfounded receiving additional services from a third party agency. Per the narrative charting dated 7/7/24 reviewed revealed that R1 was admitted to the facility with the wounds, therefore the allegation of due to neglect, resident sustained pressure injuries/bruises is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to Executive Director Elizabeth "Diane" Domingo.the state’s words, verbatim · CDSS document, Jul 17, 2024 · control 18-AS-20240711084938

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit regarding an open complaint that is currently under investigation. LPA was granted entry and met with Resident Service Director Bituin Garcia during the visit. During LPA's records review of the resident files, it was revealed Resident One (R1) Physician Report on file was last dated on 08/10/2020. LPA requested a Physician's Report 2024. Staff informed LPA an updated Physician's Report was not available for R1 for review. Residents diagnosed with Dementia must have an updated Physician's Report completed annually. A deficiency cited under Title 22 Regulation 87705(c)(5) Care of Persons with Dementia will be issued along with a plan of correction. An exit interview was conducted where a copy of this report, LIC 809-D, and appeal rights was provided to Garcia.the state’s words, verbatim · CDSS document, May 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jun 14, 2024

Care of Persons with Dementia: (c) Licensees...shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met by: Based on record review and interview, the Licensee did not comply with the above regulation for R1. Records review revealed R1's Dementia diagnosis and their last Physician's Report is dated 08/10/20. This is a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee will review regualtions regarding Care of Persons with Demntia and agrees to have Physican's Report for R1 updated. Licensee will submit updated Physician's Report to LPA by the plan of correction date 06/14/2024.

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 is without a reasonable basis. Cross reports will be made to notify the appropriate parties of the concerns reported. A exit interview was conducted and a copy of this report along with LIC811 - confidential names list was provided to Domingo. Unfoundedthe 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. A cross report will be made to the appropriate departments who have jurisdiction. This agency has investigated the complaint alleging, Staff did not seek medical attention for resident, and that resident was exposed to hazardous gas while in care. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the Business Office Manager, Barbara Guzman. Unfounded This page was intended to be blank.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 18-AS-20240226164235

Type of visit: Required - 1 Year

On February 07, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced in order to conduct the required annual inspection. LPA Mixson met with Bituin Garcia, introduced self, and stated the purpose of the visit. The File review was conducted in the office and additional forms were requested and reviewed on site. LPA Mixson toured the facility, along with the Administrator, Bituin Garcia, and inspected the inside and outside of the facility. The facility is a two story building located at 28500 Bradley Road, Sun City CA. 92586. The Facility is licensed for 74 Elderly Adults and is operating at a capacity of 69. The facility phone number is (951)679-2391 and it is operable. Physical Plant: The physical plant, is in good condition, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of this visit. The Facility has several activity rooms and each has the required furniture; such as tables, chairs, storage space, and sufficient lighting. The building temperatures throughout was per regulations. The activity rooms are equipped with the required items, per Title 22. The hot water temperature was tested in several of the restrooms, in which they each tested within the range required for regulations. The restrooms were equipped with liquid soap and paper towels. LPA Mixson toured the kitchen and staff were preparing evening meal. The facility had activity schedules posted and available for review. The Facility has emergency food and water. LPA Mixson inspected the common areas. The fire extinguisher was in the green and the Facility recently had fire inspection. Carbon monoxide alarms, along with smoke detectors were observed. There was a locked and centralized storage area for medications in the nurses station and it was locked. Medications are contained in bubble packs, and supplied by the Pharmacy. The Facility had a designated area for resident and staff files, and it was locked. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and sufficient space for activities. LPA Mixson observed monthly activity calendars, a swimming pool gated and locked. LPA Mixson reviewed staff and resident files, and conducted five staff interviews and resident interviews. There were no regulation violations observed during todays visit. An exit interview was conducted and a copy of this report was provided to Bituin Garcia.the state’s words, verbatim · CDSS document, Feb 7, 2024