306005223-2-9-2026-22-AS-APAO-DR76VH-20260210200845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005223
Report Date: 12/29/2025
Date Signed: 02/09/2026 04:52:27 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2025 and conducted by Evaluator Eboni Bentley

COMPLAINT CONTROL NUMBER: 22-AS-20251222102645

FACILITY NAME:	SUNNYCREST SENIOR LIVING		FACILITY NUMBER:	306005223
ADMINISTRATOR:	AGUIRRE, MONICA		FACILITY TYPE:	740
ADDRESS:	1925 SUNNY CREST DRIVE		TELEPHONE:	(714) 992-1999
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY:	210	CENSUS: 123	DATE:	12/29/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Melanie Washington, Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff gave medication to the wrong resident.
Staff did not follow reporting requirements.

INVESTIGATION FINDINGS:

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THIS REPORT HAS BEEN AMENDED TO INCLUDE A SECOND DEFICIENCY ON LIC809-D PAGE.
On December 29, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced to initiate the complaint investigation into the above allegations. LPA was greeted and granted entry after stating the purpose of the visit to Executive Director (ED) Melanie Washington.

During the visit, LPA toured the facility, conducted health and safety checks, and interviewed staff and residents. The following facility documents were obtained: Resident Roster, Staff Roster and contact information, Staff Schedule, Medication Policy, and In-Service documentation regarding medication administration practices. LPA also obtained the following resident records for Resident #1 (R1) and Resident #2 (R2): Identification and Emergency Information, Care Plans, Physicians Reports, Medication Administration Records (MARs), and Hospice records.

CONTINUE TO LIC9099-C....

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 22-AS-20251222102645

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNYCREST SENIOR LIVING	FACILITY NUMBER: 306005223
	VISIT DATE: 12/29/2025

NARRATIVE

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THIS REPORT HAS BEEN AMENDED TO INCLUDE A SECOND DEFICIENCY ON LIC809-D PAGE.
Regarding the allegation, Staff gave medication to the wrong resident, it is alleged that on November 3, 2025, Staff #1 (S1) administered R2’s medication of Oxycodone to R1 instead of Tramadol prescribed by R1’s doctor. Based on record review, R1’s MAR dated November 3, 2025, indicates 50mg of Tramadol was administered to R1 at 8am. However, the Morning Controlled Drug Administration Record (MCDAR), an internal record used by facility to count medication during shift change, has an entry for November 3, 2025, that was crossed out with the word “error”. There are no additional entries for the morning dose which indicates the resident was not administered Tramadol for the morning pass on November 3, 2025. This conflicts with the MAR mentioned above. A record review of R2’s MAR dated November 3, 2025 indicates 10-325mg of Oxycodone-Acetaminophen was administered to R2 six times throughout the day, however, the Controlled Medication Record (CMR), a record used by facility to count medication during shift change, has seven staff entries for November 3, 2025 with one crossed out and the words “error got wet” noted beside the date. During the investigation, interviews were conducted and three out of six staff confirmed that on November 3, 2025, Staff #1 (S1) administered R2’s medication of Oxycodone to R1 instead of Tramadol and R2 received the usual dose of Oxycodone as well. One staff interviewed stated the medication count for R1 had an extra dose of Tramadol, causing the count to be “off”. A second staff stated R2 was missing a dose of Oxycodone, which was causing that resident’s count to be “off”. A third staff member stated they were aware that R1 was given R2’s medication on November 3, 2025, as staff counted medication and discovered the wrong medication was given to R1 instead of R2 on that date. S4 stated they do not recall the errors occurring on that date and could not confirm or deny if a medication error did or did not happen. S4 reviewed the records and stated that a Medication Destruction Record is used by facility when any medication is damaged or disposed of but could not provide any record of disposal for R1 and R2 on November 3, 2025. Interviews were attempted with residents and LPA was unable to qualify Resident #1 due to diagnosis and Resident #2 was out of the facility at the time of the visit.

Regarding the allegation, Staff did not follow reporting requirements, it is alleged that staff did not report the medication error for R1 to resident's family, physician, and the Department. Interviews were conducted and three out of six staff confirmed the allegation. One staff stated R1's family was not informed about the medication being administered incorrectly. A second staff stated R1's physician was not informed about the medication error. A third staff stated they were specifically told not to document the medication error of R2’s medication of Oxycodone being administered to R1 instead of Tramadol prescribed by R1’s doctor. A record review revealed that as of December 29, 2025, no incident reports were submitted to the Department regarding R1’s medication error. Executive Director was interviewed and denied knowledge of the medication error that occurred on November 3, 2025.

Based on LPA's observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the allegations Staff gave medication to the wrong resident and Staff did not follow reporting requirements are deemed SUBSTANTIATED. Deficiencies are being cited per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report, LIC 9099-D, and appeal rights were provided at exit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20251222102645

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNYCREST SENIOR LIVING	FACILITY NUMBER: 306005223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/16/2026 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that they will submit the incident report regarding R1's medication error to the Department today. THIS IS AN AMENDED REPORT
	8 9 10 11 12 13 14	Based on LPA's observation, interviews, and record review, the facility did not report R1's medication error to R1's family and physician and did not submit an report to the Department within 7 days of the event, which poses a potential Personal, Health, and Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type B 03/05/2026 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident ... provided all ... requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility will retrain all staff on the section cited above and submit proof of attendees to CCLD via email by POC due date. THIS IS AN AMENDED REPORT
	8 9 10 11 12 13 14	Based on observation, interviews, and record review, the facility did not administer medication to R1 as prescribed, which poses a potential Health, Safety, and Personal Rights risk to persons in care. Interviews conducted corroborated that R1 was administered R2's medication on 11/3/2025.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

LIC9099 (FAS) - (06/04)

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