Sunset Coast Assisted Living

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced visit to deliver official documents regarding the facility. LPA disclosed the purpose of the visit with staff. No deficiencies were cited in accordance with the California Code of Regulations. An exit interview was conducted with staff, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Aug 24, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) conducted an unannounced visit to conduct a visit in response to a request of change in capacity for one bedridden resident. LPA disclosed the purpose of the visit with Licensee Patricia Tapia. LPA toured the facility and reviewed facility records. No deficiencies were cited in accordance with the California Code of Regulations. An exit interview was conducted with Licensee Patricia Tapia, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Jul 6, 2026

Allegation investigated: Staff did not protect resident from verbal abuse

On March 18, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver the findings regarding the above-referenced allegation. LPA was greeted by Staff Betty Valdez. LPA Garcia-Centeno met with Licensee Patricia Tapia via telephone to discuss the investigative findings. The Department’s investigation included facility observations, record reviews, and interviews with staff, residents, responsible parties, and outside sources. On November 25, 2025, Community Care Licensing (CCL) received a complaint alleging that staff did not protect Resident 1 (R1) from verbal abuse by Resident 2 (R2). The complaint alleged that R2 had been verbally aggressive toward R1 for an extended period of time and that staff intervention had not been sufficient to stop the behavior. (Continue at LIC9099C) Substantiated (Continue from LIC9099) The reporting party indicated the situation had been ongoing for several months and was causing emotional distress to R1. Staff were provided the LIC811 Confidential Names to identify R1 and R2. During the investigation, LPA conducted multiple visits to the facility and interviewed residents, staff, and outside sources who provided consistent accounts regarding R2’s behavior toward R1. Records reviewed during the investigation confirmed that R2 has diagnoses including dementia, confusion/disorientation, and aphasia, and has a documented history of aggressive and impulsive behaviors. Admission records showed that R1 has resided at the facility since December 2020 and that R2 was admitted in September 2023. Facility records indicated that R2 experienced a change in condition beginning around July 2025 and that staff and R2’s medical providers have been addressing behavioral symptoms related to dementia, including medication adjustments. During an interview conducted on December 3, 2025, R1 reported that R2 frequently yells and curses in Spanish toward R1 for no apparent reason. R1 stated that R2 becomes angry when R1 performs normal activities such as turning on the bedroom light, watching television, or speaking on the telephone. R1 reported that R2 uses profanity and threatening language, including statements instructing R1 to leave the room. R1 stated that due to the verbal aggression, R1 often leaves the bedroom and sits in the living room to avoid confrontation. R1 reported that staff frequently instruct R1 to leave the room when R2 becomes upset, rather than redirecting or removing R2. R1 stated that R1 feels unable to freely use the bedroom, television, or personal space due to R2’s behavior and reported considering moving from the facility because the living environment no longer feels comfortable. R1 also reported a physical incident in which R2 threw a water bottle in R1’s direction while yelling and cursing. R1 reported that the bottle was thrown while R1 was seated on the bed getting dressed. Although no injury was reported, the act of throwing the object caused concern and contributed to fear that the situation could escalate. (Continue at LIC9099D) (Continue from LIC9099C) Staff interviews corroborated R1’s statements regarding ongoing verbal aggression. Staff confirmed that R2 frequently directs profanity toward R1, including derogatory and aggressive language in Spanish. S1 stated that R2 “does not like R1” and that R1 is often the target of R2’s outbursts. S1 further reported that R2’s behavior worsened around November 2025 and that R2 frequently yelled at R1 using profanity and other offensive language. Staff also confirmed the water bottle incident, reporting that on or about November 25, 2025, at approximately 6:45 a.m., R2 became angry when R1 turned on the bedroom light while getting dressed. According to staff, R2 began yelling at R1 and threw a water bottle toward R1 while cursing. Staff reported that the bottle did not strike R1 and that no injuries were observed. However, the incident demonstrates an escalation from verbal aggression to physical behavior directed toward R1. Staff reported that incidents involving R2’s aggression were documented in the facility’s electronic documentation system and had been reported to the Administrator. Records review confirmed the documentation. Additional staff interviews confirmed that when R2 becomes verbally aggressive, staff intervene by separating the residents, typically by asking R1 to leave the bedroom and sit in the living room while R2 remains in the shared room. Staff indicated this approach is used because R2 becomes more agitated if asked to leave the room. Staff reported that R2 has previously struck caregivers and can become difficult to manage during outbursts. Interviews with other residents living in the facility further corroborated the presence of ongoing verbal aggression by R2 toward R1. Resident 3 stated that R2 frequently yells loudly at R1 and that the yelling can be heard from other areas of the home. Resident 4 reported that R2 “yells and screams all the time” and becomes angry toward R1, which makes other residents uncomfortable. Resident 6 also confirmed hearing R2 yell at R1 frequently and stated that R1 often leaves the bedroom and goes to the living room because of the yelling. (Continue at LIC9099C) (Continue from LIC9099C) Interviews with outside sources also supported the allegation. A medical provider who visits the facility regularly to provide services reported witnessing R2 yelling at R1 and using offensive language toward R1 during visits. The outside source reported that R2 directs this behavior specifically toward R1 and not toward other residents. It was stated that staff typically intervene by separating the residents and that R1 often leaves the room to avoid confrontation. Although no physical aggression between the residents was observed during those visits, the outside source indicated concern that R1 must routinely tolerate verbal abuse in the living environment. Similarly, another medical provider who has provided services at the facility reported witnessing R2 yelling aggressively toward R1 and occasionally toward staff. It was reported that during one incident, R2 became aggressive toward R1 and the provider requested that staff remove R1 from the room so that R2 would calm down. In addition, an outside source reported overhearing R2’s verbal aggression toward R1 during telephone calls. It was reported that R2 yelled profanity and threats toward R1, including statements in Spanish instructing R1 to leave the room and threatening harm. During the interview, it was stated that the verbal aggression had been occurring for several months and had caused emotional distress for R1. Concern was also expressed after learning about the water bottle incident, as the behavior appeared to be escalating. During facility observations conducted on December 3, 2025, LPA observed that R2 was eating separately from other residents because R2 did not want to sit near R1. During the visit, R1 was observed eating with other residents in the dining area while R2 ate alone in the living room. Interviews and observations confirmed that R1 frequently spends time in the living room rather than the shared bedroom due to R2’s behavior. Although staff reported that they intervene when R2 becomes verbally aggressive and separate the residents to de-escalate the situation, the investigation found that R2’s verbal abuse toward R1 has been ongoing for approximately nine months and continues to occur despite staff intervention. (Continue at LIC9099C) (Continue from LIC9099C) The separation strategy often results in R1 being removed from the shared bedroom and common areas in order to avoid conflict, which limits R1’s ability to use personal living space. Based on observations, record reviews, and interviews with staff, residents, and outside sources, there was sufficient evidence to support the allegation that staff did not protect R1 from verbal abuse. Verbal outbursts by R2 were reported. The evidence indicated that staff took actions to mitigate behaviors by separating the residents; however, the measures taken have not ensured that R1 is protected from abuse and infringe on personal rights to a safe living environment and personal space. The preponderance of evidence standard was met; therefore, the allegation is deemed Substantiated. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations, and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Licensee, Patricia Tapia. An exit interview was conducted with Licensee Patricia Tapia via telephone. A copy of this report, LIC9000D, LIC811 Confidential Names, and the Licensee Appeal Rights (LIC 9058, 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 08-AS-20251125133020

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 20, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions … This requirement was not met as evidence by: Based on interviews, records review and observations it was determined the licensee did not protect R1 from verbal abuse by another resident (R2). This posed a potential health and safety risk for one (1) of six 6 residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Licensee agreed to submit a plan of corrections that clearly outlines and addresses how the facility will ensure residents are protected from verbal abuse and that residents’ personal rights are maintained. Licensee agreed to submit the incident report discussed on this report. In addition, Licensee agreed to conduct additional in service training with all staff including Administrators and Licensee by an independent contractor on the regulation cited as it relates to personal rights. Licensee agreed to submit documentation to CCL by POC Date of 4/20/2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a Case Management visit to cite a deficiency disclosed during a complaint investigation conducted on December 6, 2025. LPA met with Licensee Patricia Tapia via telephone and discussed the details of the violation. During staff interviews conducted during the complaint investigation, it was disclosed that there have been multiple incidents of verbal abuse between two residents, in which Resident 1 (R1) has been the target of verbal aggression by Resident 2 (R2). Both residents have been roommates for an extended period of time. Records reviewed indicated that R1 has resided at the facility since December 2020 and R2 was admitted in September 2023 when they became roommates. Staff were provided with LIC811 to identify R1 and R1 for plan of correction. Staff interviews indicated that the verbal abuse began around July 2025, when R2 experienced a change in condition and began directing verbal aggression toward R1. Staff reported that the incidents involved R2 yelling at and verbally targeting R1 on multiple occasions. Staff further reported that on November 25, 2025, R2 threw a water bottle in the direction of R1. The water bottle did not strike R1 and R1 did not sustain any injuries. Staff indicated that the incident was addressed internally by staff; however, it was not reported to Community Care Licensing. (Continue at LIC809D) (Continue from LIC809) During interviews conducted with staff, it was confirmed that none of the incidents involving R2’s verbal aggression toward R1 had been reported to Community Care Licensing as required by California Code of Regulations, Title 22. Staff stated that the incidents were not reported because they believed R2’s aggressive behavior was related to R2’s documented dementia diagnosis. The California Code of Regulations, Title 22, requires licensees to report incidents involving resident abuse, including verbal abuse and aggressive behavior between residents that may threaten the health, safety, or personal rights of a resident. Based on staff statements and information obtained during the investigation, the facility failed to report the incidents involving R2’s verbal abuse toward R1, including the incident on November 25, 2025, in which R2 threw a water bottle toward R1. Pursuant to the California Code of Regulations, Title 22, Division 6, a deficiency is being cited on the attached LIC 809D. The facility was advised that the November 25, 2025 incident must be documented and reported to Community Care Licensing. In addition, a plan of correction was developed with Licensee Patricia Tapia. An exit interview was conducted with Licensee Patricia Tapia, to whom a copy of this report, the LIC 809D Deficiency Report and LIC811 Confidential Names form were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 20, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, (D)Any incident which threatens the welfare, safety or health of any resident, ... This requirement was not met as evidenced by: Based on records review and interviews it was disclosed that the licensee did not report as required numerous instances of verbal abuse to a resident (R1) by another resident (R2). This posed a potential health and safety risk to two (2) six (6) residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Licensee agreed to submit an the incident report discussed in this report. In addition, the licensee agreed to conduct in service training to all staff including Administrators and licensee by an independent contractor. Licensee agreed to submit documentation for POC to CCL by due date of 4/20/2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. Upon arrival, LPA identified herself and was granted entry by Administrator Karina Lopez, and explained the purpose of the visit. It was noted that Caregiver Beatriz Valdez had a current criminal record clearance; however, she was not associated with this facility. According to the facility license, the facility is approved for a maximum capacity of six (6) elderly residents ages 60 and above, all of whom may be non-ambulatory, and has a hospice waiver for up to two (2) residents. During today’s inspection, six (6) residents were in care, all non-ambulatory. The facility does not have a secured perimeter or delayed-egress doors. LPA Garcia-Centeno, accompanied by Caregiver Valdez, toured the interior and exterior of the facility, including resident bedrooms. The facility was clean, well-maintained, and free of obstruction or slip hazards. Resident bedrooms contained required furnishings, and all doors, toilets, and showers were operational. Adequate linens and hygiene supplies were available. The facility provided sufficient space and equipment for dining, laundry, visitation, meetings, and activities. The facility’s internal temperature, refrigerator, and freezer were within regulatory ranges. Hot water temperature in the resident-accessible kitchen faucet measured 110 degrees, which is within regulatory limits. The facility maintained at least two (2) days of perishable food and seven (7) days of non-perishable food, all properly stored. Cooking and dining equipment were present. No sharp objects, toxic chemicals, fireplaces, or open-faced heaters were accessible to residents. (Continue at LIC809C) (Continued from LIC809) Medications were properly labeled and stored in locked areas. Confidential resident and staff records were secured. No pools or bodies of water were observed. Per the Administrator, no firearms or ammunition are kept on the premises. Smoke alarms, carbon monoxide detectors, emergency lighting, and the facility telephone were operational. Fire extinguishers were serviced within the last 12 months on October 22, 2025. The first aid kit was complete and accessible. Required licensing postings were observed. Emergency drills were conducted in August 2025.. LPA interviewed staff and residents and reviewed staff and resident files. No licensing concerns were identified through interviews. Resident files contained required documentation. Staff files included proof of current first aid training. The Administrator provided proof of current business liability insurance. Civil penalties in the amount of $500 were assessed for violations and are documented on the attached LIC 421. A plan of correction was developed in coordination with Administrator Karina Lopez. An exit interview was conducted with Administrator Karina Lopez. She was provided copies of this report, LIC 809D Deficiencies, LIC 421 Civil Penalty, and Licensee/Appeal Rights (LIC 9058, 03/22).the state’s words, verbatim · CDSS document, Nov 17, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced case management visit at the facility. LPA was greeted at the front entrance by Caregiver,Beatriz Valez and granted entry after identifying herself. LPA explained the purpose of the visit to Administrator, Karina Lopez. During the visit, LPA Garcia-Centeno discuss the Title 22 regulation requirement for background checks and association of individuals to the facility prior to first day of work. During the annual inspection a caregiver was associated to the facility. An exit interview was conducted with Administrator, Lopez a copy of this report, and Licensee/Appeals Rights (LIC 9058 01/16) was provided.the state’s words, verbatim · CDSS document, Nov 17, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Marisela Garcia-Ceteno conducted a virtual Case Management visit to deliver an amended complaint report issued on 8/18/2025. LPA identified herself to Administrator, Karina Lopez and discussed the purpose of the visit. LPA reviewed the amended report with Administrator, Lopez No deficiencies were issued during this visit. An exit virtual interview was conducted with Administrator Lopez, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via email. An electronic read receipt confirmation was requested to be sent by Administrator, Lopez upon receipt of the documents.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Staff abandoned resident Staff did not allow resident to have visitors Staff did not keep resident's personal information confidential

On August 18, 2025, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a telephone conference with Licensee, Patricia Tapia and Administrator, Vanessa Nunez to present investigative findings. The Department’s investigation included a facility tour, record review, and interviews with staff and external sources. Allegation 1: Staff abandoned resident (R1). On October 10, 2024, Community Care Licensing (CCL) received a complaint alleging that staff abandoned R1. Specifically, it was alleged that on October 7, 2024, staff left R1 outside a hospital without identification. (Continue at LIC9099C) Unsubstantiated (continue from LIC9099) Review of R1’s physician’s report indicated that R1 was independent and able to make personal decisions regarding care and supervision. Interviews and records confirmed that R1’s placement social worker arranged non-emergency transport for a medical evaluation. Records also showed that R1 was in the process of transferring to a higher level of care. R1 was admitted to the facility on July 1, 2024, and discharged to a higher level of care on October 7, 2024. It was further determined that R1 did not have a current identification card at the time of transport. R1’s social worker was actively assisting with obtaining proper identification. There was no corroborating evidence that staff abandoned R1 at the hospital. Note: R1 was not available for interview during the investigation. Allegation 2: Staff did not allow R1 to have visitors. It was alleged that on August 2, 2024, R1 was denied visitation. Interviews with staff, residents, and outside sources, as well as review of the visitor log, confirmed that R1 received visitors on multiple occasions while residing at the facility. Review of the facility’s visitor policy revealed no restrictions on visitation. At the request of an outside agency, staff were asked to supervise R1’s visits to ensure health and safety. No corroborating evidence was found to support this allegation. Allegation 3: Staff did not keep R1's personal information confidential. It was alleged that staff disclosed R1’s personal information in a group text message with multiple parties, including an unknown recipient. Review of the text message and interviews revealed that R1 had authorized staff to share certain information for the purpose of coordinating a new placement. Staff acknowledged that an unknown number was inadvertently added to the group conversation but reported that the number was deleted immediately upon discovery. The review of the information disclosed was not deemed private or in violation of R1’s confidentiality. (Continue at LIC9099C) (Continue from LIC9099C) Note: This is an amended report of the report issued on 8/18/2025 Conclusion Based on the investigation—including record reviews and interviews with staff and external sources—there was insufficient evidence to substantiate the allegation. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with Administrator, Karina Lopez. A copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were provided via email at sunsetcoast.lopez@gmail.com , an electronic email receipt confirmed receipt of report.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 08-AS-20241010102943

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required Annual Inspection. The facility file was reviewed before the visit. LPA identified herself and was granted entry by Caregiver, Leticia Castro. LPA met with Administrator, Patricia Tapia, to whom she disclosed the purpose of the visit. All staff present had current criminal record clearance. According to the facility’s license, the facility has a maximum capacity of six (6) elderly residents ages 60 and above; all of whom may be non-ambulatory; a hospice waiver approved for two (2) residents. During today’s inspection, there were a total of six (6) residents in care, of which five (5) were non-ambulatory, and none of the residents were on hospice. The facility does not feature a secured perimeter or delayed egress doors. LPA Garcia-Centeno was accompanied by the Caregiver, Leticia Castro while touring the interior and exterior of the facility. In addition, the residents’ rooms were inspected. The facility was clean and in good repair. Pathways were free of obstruction and slip hazards. The residents’ bedrooms contained the required furnishings. The doors, toilet, and shower were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities for the residents in care. The facility’s internal temperature, refrigerator, and freezer temperatures were within the regulatory range. During today’s visit, LPA observed, via measurement with a thermometer, that the hot water temperature from the bathroom faucet accessible to residents was within the regulatory range, at 120 degrees F. (Continue at LIC809C) Continue from LIC809 There were at least 2 days of perishable food, and at least 7 days of non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled as required and stored in locked areas. Residents and staff confidential records were appropriately maintained electronically, and the required licensing physical files were available at the facility. No pools or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. The fire extinguishers were serviced within the last 12 months. The first aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and residents present during the visit and reviewed staff and residents' records. LPA interviews did not raise any licensing concerns. The residents' files that LPA reviewed contained the required documents. Staff records contained proof of current first aid training. The administrator presented proof of current/active business liability insurance as required by Title 22 regulations. No deficiencies were cited or observed on this date. The Licensee was provided a copy of her appeal rights (LIC9058 03/22). An exit interview was conducted with Administrator, Patricia Tapia, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 16, 2024