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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005223
Report Date: 05/15/2026
Date Signed: 05/15/2026 03:03:26 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
08/19/2025 and conducted by Evaluator Eboni Bentley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250819142857
FACILITY NAME:SUNNYCREST SENIOR LIVINGFACILITY NUMBER:
306005223
ADMINISTRATOR:AGUIRRE, MONICAFACILITY TYPE:
740
ADDRESS:1925 SUNNY CREST DRIVETELEPHONE:
(714) 992-1999
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:210CENSUS: 110DATE:
05/15/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Melanie Washington - Executive DirectorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident developed pressure injuries due to lack of care and supervision.
Resident did not receive medical attention timely.
Facility did not notify family regarding pressure injuries.
INVESTIGATION FINDINGS:
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On May 15, 2026, Licensing Program Analyst (LPA) Eboni Bentley made an unannounced visit for the purpose of delivering the investigation findings into the above allegations. LPA met with Executive Director Melanie Washington and explained the reason for the visit.

On August 19, 2025, the Department received a complaint alleging neglect/lack of care and supervision of Resident #1 (R1) and the investigation was initiated on August 21, 2025. During the course of the investigation, the Department interviewed twenty-nine staff and witnesses and obtained the following documentation: Resident/Staff Roster, Staff Contacts, Caregiver Duty Statement, Facility Progress Notes, Facility Shower Sheets, Caregiver and Med Tech Schedules, Physician Communications, R1’s Identification and Emergency Information, Physician’s Report, Preplacement Appraisal Information, Residence & Care Agreement, Service Plan, Unusual Incident Reports, Home Health Records, Kaiser Medical Records, and Photos Taken.
CONTINUE TO LIC9099-C........
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
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 6
Control Number 22-AS-20250819142857
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: 05/15/2026
NARRATIVE
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...... CONTINUE from LIC9099

The investigation revealed the following:

Regarding the allegation, Resident developed pressure injuries due to lack of care and supervision, the investigation is as follows: On August 18, 2025, R1 was found to have a stage 3 pressure injury on the coccyx, measuring 3cm x 4 cm x 0.3 cm; a linear ulceration on the left posterior thigh (probably friction and moisture related), measuring 0.5cm x 7cm x 0.2cm, and an unstageable pressure injury on his right heel, measuring 3cm x 4cm x unknown depth. The facility first noted an open wound on R1’s right heel and a pressure injury on his coccyx on August 11, 2025. During interviews, facility caregivers admitted that they were not repositioning R1 in his wheelchair and that the wounds were likely the result of continuous sitting on the wheelchair with his heel pressed against the footrest or floor. On August 13, 2025, R1’s coccyx pressure injury was documented at stage 2, measuring 5.2cm x 1.3cm, but measurements for the heel wound were not documented. The facility only arranged for R1’s hospitalization for assessment after his daughter/Power Of Attorney (POA) requested it, but by this time, the wounds had progressed to greater than stage 2. On August 18, 2025, R1 was admitted to Kaiser Anaheim Hospital due to multiple newly discovered pressure injuries that were not reported to his POA.

Based on staff admissions, following the discovery of these wounds, R1 continued being placed in his wheelchair, at his request, but was not being repositioned in it. The allegation that R1 sustained stage 3 and unstageable pressure injuries because of facility neglect is therefore Substantiated.



Regarding the allegation, facility did not seek medical attention in a timely manner, the facility was aware at least one full week before R1’s hospitalization, that resident had developed pressure injuries. Based on records obtained, Staff 1 (S1) was the first caregiver to document a “blister” on R1’s right heel, which was observed while providing R1 a bed bath on August 11, 2025. Per progress notes, Staff 2 (S2) documented on the progress notes that S1 reported having observed an “open wound” on R1’s right heel while providing a bed bath.


CONTINUE TO LIC9099-C........
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20250819142857
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: 05/15/2026
NARRATIVE
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S2 observed fluid leakage from R1’s legs and increased swelling to both feet, with the skin of both feet “very dry and cracking.” S2 elevated R1’s legs to reduce the swelling and planned to continue monitoring the resident’s skin condition and reporting changes. S2 notified home health of the open wound via fax and called the office of his Primary Care Physician (PCP) about the “open blister.” Records reviewed indicate the facility faxed PCP’s office to report that R1’s legs are more swollen than usual and leaving fluid and faxed Excell Home Care (Home Health) to report an “open wound on R1’s right heel, about a quarter size.” R1 complained of pain and discomfort when applying pressure. The facility requested for the Home Health to send a nurse to check the wound as soon as possible. On August 12, 2025, Staff 3 (S3) noted that Excell Home Care would visit R1 on August 13, 2025. Staff 4 (S4) documented on August 13, 2025 that she spoke with POA to request softer/looser shorts to prevent friction and tightness in R1’s buttocks due to “skin peeling.” S4 also called the PCP’s office to request assessment of this skin peeling. Later that day, S3 noted their belief that Home Health had not visited R1 as arranged, and requested that a follow up be done. On August 14, 2025, while providing a sponge bath, Staff 6 (S6) documented on Shower Sheets redness and “peeling skin” to R1’s buttocks area and an “open blister” on the right heel. On August 15, 2025, R1 was placed on alert charting for 72 hours due to complaints of leg pain. Later that day, Staff 6 (S6) called R1’s PCP’s office to request Home Health wound care “for bedsores on the buttocks and pressure bedsore on the left heel.” S5 applied Calmoseptine on R1’s buttocks, put him in bed after lunch, and elevated his legs. On August 16, 2025, S6 again applied Calmoseptine to R1’s “private area” and placed a patch on his heel.

The facility was aware on August 11, 2025, one full week before R1’s hospitalization, that he had developed pressure injuries. Although the facility notified Excell Home Care (Home Health) of the change in condition in a timely manner, it failed to ensure R1 received treatment. The facility did not inquire with Home Health about the progression of the wounds, had no documentation of treatment as required by 22 CCR § 87631, was not aware appointments were being cancelled due to R1’s purported refusals and failure to respond to agency calls, and did not even know whether home health was providing treatment. Home Health did not visit R1 between July 26, 2025 and August 12, 2025; and while the Home Health did treat the coccyx wound on August 13, 2025, this was the last time treatment was provided, and it never treated the right heel wound. The facility only arranged for R1’s hospitalization for assessment after his POA requested it, but by this time, the wounds had progressed to greater than stage 2. The allegation that the facility failed to ensure R1 received timely medical attention for his pressure injuries is therefore Substantiated.

CONTINUE TO LIC9099-C........
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20250819142857
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: 05/15/2026
NARRATIVE
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Regarding the allegation, Facility did not notify family regarding pressure injuries. On August 18, 2025, around 3:00pm, S2 called Daughter/Power Of Attorney (POA) and informed them that the facility was trying to get a hold of R1’s doctor to get medicine for pressure injuries, explaining that the wounds were on R1’s foot, buttocks, and inner thigh. After reviewing pictures received by staff, the POA asked the facility to send R1 to Kaiser Anaheim Hospital. A Kaiser physician called POA to report that the pressure injuries were at stage 3. On August 19, 2025 Witness 1 (W1) submitted a SOC341 to The Department to report that R1 was admitted to Kaiser Anaheim Hospital on August 18, 2025 due to multiple newly discovered pressure injuries that were not reported to his daughter/POA. It was reported that during visits with family, R1 wore “diabetic shoes,” and the POA never saw the resident’s exposed feet, but the facility bathed R1 at least twice a week and also changed his clothes daily. Although the facility first became aware of the pressure injuries on August 11, 2025, the POA was not aware until August 18, 2025, prior to requesting R1 be sent to the hospital. Therefore, the allegation that the facility did not notify family regarding pressure injuries is deemed Substantiated.

Therefore, based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Resident developed pressure injuries due to lack of care and supervision, facility did not seek medical attention in a timely manner, and Facility did not notify family regarding pressure injuries are deemed SUBSTANTIATED. Deficiencies are being cited on the attached LIC 9099Ds, as 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-Ds, LIC 811, and appeal rights were provided at exit.
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20250819142857
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: 05/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2026
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidenced by:
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Executive Director (ED), Melanie Washington stated that residents with pressure injuries will be repositioned according to their doctor’s orders and care plan, the licensee will ensure all staff are trained to meet the resident’s needs, and ED will submit an Acknowledgement of Understanding of the said deficiency. The above statement and proof of training will be submitted to LPA via email by POC due date.
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Based on interviews and record review, licensee did not find a solution necessary to prevent and address R1’s pressure injuries, R1 continued being placed in his wheelchair, and was not being repositioned in it, which posed an immediate Health, Safety, and Personal Rights risk to persons in care. Due to lack of care and supervision, R1 sustained stage 3 and unstageable pressure injuries.
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Type A
05/16/2026
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, ... medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
This requirement was not met as evidenced by:
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Executive Director (ED), Melanie Washington stated that all care staff will be trained on when to seek medical attention to ensure resident’s needs are met, and ED will submit an Acknowledgement of Understanding of the said deficiency. The above statement and proof of training will be submitted to LPA via email by POC due date.
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Based on interviews and record review, R1 was observed with pressure injuries one week before hospitalization and the facility did not seek immediate medical attention, which posed an immediate Health, Safety, and Personal Rights risk to persons in care. The facility only arranged for R1’s hospitalization for assessment after his POA requested it.
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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: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20250819142857
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: 05/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2026
Section Cited
CCR
87211(a)(1)
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87211(a)(1) Reporting Requirements (a) Each licensee shall … (1) A written report ... to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) .. of the case. This requirement was not met as evidenced by:
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Executive Director (ED), Melanie Washington stated that all care staff will be trained on Reporting Requirements Section 87211 of the California Code of Regulations, and ED will submit an Acknowledgement of Understanding of the said deficiency. The above statement and proof of training will be submitted to LPA via email by POC due date.
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Based on interviews and record review, the facility first became aware of the pressure injuries on August 11, 2025, the POA was not aware until August 18, 2025, prior to requesting R1 be sent to the hospital, which posed a potential safety risk to persons in care.
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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: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6