Sungarden Terrace

Allegation investigated: Licensee did not give resident medication as prescribed.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Susan O'Shaugnessy. The Complainant alleged that Licensee did not give a resident medication as prescribed. Specifically, they claimed that facility staff in practice did not give Resident #1 (R1) their ABH (a compound of Ativan, Benadryl, Haldol) topical gel at the required frequency called for in R1’s hospice physician’s orders. [See LIC811 Confidential Names List for a description of R1.] CCLD’s investigation involved multiple unannounced facility tours/welfare checks, review of relevant facility and hospice care records on R1, and interviews of pertinent facility staff and outside sources. [CONTINUED ON LIC 9099, 1 of 2] Substantiatedthe state’s words, verbatim · CDSS document, Apr 23, 2026 · control 08-AS-20260408093545

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

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 a broken arm while in care

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Administrator Susan O'Shaughnessy. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. It was alleged that resident sustained a broken arm while in care. Interviews revealed on 08/12/2025 Resident 1 (R1) was in the memory care unit. Interviews revealed there were two staff on the overnight shift a caregiver and a med tech who was training a new staff. Interviews revealed while Staff 1 (S1) the med tech and trainee were upstairs, S2 (the caregiver) was downstairs covering the memory care unit. Interviews revealed that staff are supposed to do rounds every 2 hours. Interviews revealed that according to camera footage in the facility that S2 rounds began at 11:11pm, another was conductthe state’s words, verbatim · CDSS document, Mar 19, 2026 · control 08-AS-20250917154616

Allegation investigated: The facility did not provide enough staff for adequate resident care. Unqualified Facility staff administered medications to residents

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Administrator Susan O'Shaughnessy. On 9/4/25 it was alleged that the Licensee did not provide enough staff for adequate resident care. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Interviews were conducted with three staff members, three residents, and three outside sources. All staff reported that staffing assignments are posted daily and coverage is sufficient to meet resident needs, including assistance with ADLs, medication administration, and timely call-light response. (Continued on LIC9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2026 · control 08-AS-20250904133832

Allegation investigated: Facility does not have hot water. Staff do not provide residents with a comfortable temperature. The facility does not provide quality food.

Licensing Program Analyst (LPA) Amy Domingo made an unannounced visit to conduct an investigation on the above-mentioned allegations. LPA met with Executive Director Susan O'Shaughnessy and discussed the basic elements of the complaint. The Department’s investigation consisted of staff, resident, outside source interview s and a facility tour. On January 28, 2026, Community Care Licensing (CCL) received a complaint alleging that the Facility does not have hot water. During the visit, the LPA tested hot water temperatures in resident bathrooms and kitchen areas using a calibrated thermometer. Regulations requires that hot water in resident-use fixtures be maintained between 105°F and 120°F to ensure comfort and safety. Observations showed hot water temperatures measured at 100 degrees Fahrenheit, which is within the regulatory range. Faucets were functioning properly, and residents were observed using sinks and showers without difficulty. No signs of plumbing malfunction were noted. A rthe state’s words, verbatim · CDSS document, Feb 12, 2026 · control 08-AS-20260128102314

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 neglected residents care needs Licensee did not uphold visitor policy. Staff took away residents cell phone.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Administrator Susan O'Shaughnessy. Department’s investigation consisted of staff and resident interviews, interviews with outside sources and LPA observations in the memory care area of the facility. On June 20, 2025, Community Care Licensing (CCL) received a complaint alleging that staff neglected the care needs of Resident #1 (R1). More specifically R1 has lost a lot of weight recently and was itching. Hospice records indicated R1 has diagnoses including dementia, lung mass, and congestive heart failure, with documented periods of agitation and refusal of care. During the visit, LPA observed R1 being offered multiple food options and staff encouraging them to eat. R1 declined some items but accepted others, but ate very little. No visible signs of itching were observed. Interviews witthe state’s words, verbatim · CDSS document, Aug 18, 2025 · control 08-AS-20250620154824

Allegation investigated: Facility did not maintain a comfortable temperature for a resident in care.

Licensing Program Analyst (LPA) Amy Rodgers made an unannounced visit to conduct an investigation on the above-mentioned allegation. LPA met with Executive Director Susan O'Shaughnessy and discussed the basic elements of the complaint. The Department’s investigation consisted of staff and resident interviews and a facility tour. On May 5, 2025, Community Care Licensing (CCL) received a complaint alleging that R1's room and the entire facility were very cold. An interview with Resident #1 (R1) confirmed they cannot control their room's temperature. Direct observation in R1's room reflected a temperature of 76 degrees. Interview with the Executive Director and R1 confirmed measures have been taken, such as insulated draperies, offering of different room accommodations, offering individual room heaters and extra blankets, as well as timely responses to requests of modifying R1's room temperature to make R1 feel more comfortable in his room. (Coninued on LIC9099) Unsubstantiatedthe state’s words, verbatim · CDSS document, May 12, 2025 · control 08-AS-20250506094003

Allegation investigated: Licensee staff did not take steps to prevent the spread of a communicable disease. Licensee staff does not ensure residents receive adequate medical treatment.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to conduct a complaint investigation and deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Administrator Susan O'Shaughnessy. On April 14, 2025, Community Care Licensing (CCL) received a complaint alleging that licensee staff did not take steps to prevent the spread of a communicable disease and licensee staff does not ensure residents receive adequate medical treatment. The Department’s investigation consisted of staff and resident interviews, interviews with outside sources, and a facility tour of common areas and resident rooms in the memory care area of the facility. Regarding the allegation, licensee staff did not take steps to prevent the spread of a communicable disease. More specifically, residents were experiencing scabies symptoms in February 2025 and continued to exhibit symptoms of scabies in April 2025. (Continued on LIC 9099the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 08-AS-20250414103911

Allegation investigated: Staff does not provide a comfortable room temperature for resident.

Licensing Program Analyst (LPA) Amy Rodgers conducted a facility visit to open a complaint and deliver findings. LPA gained access to the facility, identified herself and met with Administrator Susan O'Shaughnessy to whom was explained the purpose of the visit. The Department’s investigation consisted of staff and resident interviews and a facility tour. On February 12, 2025, Community Care Licensing (CCL) received a complaint alleging that facility staff did not maintain a comfortable temperature for resident (R1), [a LIC 811 Confidential Names List was provided to staff to identify the resident]. It was specifically alleged that the heat does not run long enough to maintain a comfortable temperature in R1’s apartment. (continue at LIC9099C) (Continued form LIC 9099) Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 13, 2025 · control 08-AS-20250212142931

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

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