331881358-6-7-2023-18-AS-JDHS-CT6NH6-20230626102809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881358
Report Date: 06/07/2023
Date Signed: 06/07/2023 01:43:42 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2023 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230601165701

FACILITY NAME:	SUN CITY GARDENS		FACILITY NUMBER:	331881358
ADMINISTRATOR:	ROBYN REBOLLAR		FACILITY TYPE:	740
ADDRESS:	28500 BRADLEY ROAD		TELEPHONE:	(951) 679-2391
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	74	CENSUS: 66	DATE:	06/07/2023
		UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Bituin Garcia, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Uncleared adult is providing care to residents
Resident is being financially abused by staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit at the facility to start the investigation into the above allegations. The LPA met with Interim-Administrator, Tierre Thornton, and informed her of the purpose for her visit.

The investigation included staff/resident interviews, records review and receipt of relevant documentation.

The Department received a report alleging Staff One (S1) is working in the facility without a fingerprint clearance. Records reveal S1 does not have a current fingerprint clearance to work in the assisted living unit of the facility. The Interim-Administrator reported S1 does not work for the company, rather S1 was contracted by Resident One (R1) as a private caregiver. The Administrator reported R1 resides in the Independent Living Unit (IU) of Sun City Gardens, which is owned by the same corporation, though is not licensed by the Department. The LPA reviewed the staff roster and did not observe S1's name listed on the report. Therefore, due to S1 not

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230601165701

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUN CITY GARDENS	FACILITY NUMBER: 331881358
	VISIT DATE: 06/07/2023

NARRATIVE

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working in the licensed facility, this allegation is deemed UNFOUNDED.

Another report was received alleging S1 is financially abusing Resident One (R1). Staff interview and a resident roster revealed R1 resides in the IU of Sun City Gardens. The LPA also spoke with R1, who confirmed their identity, and reported they reside in the IU of the facility. Additional investigation could not be conducted, due to the Department having no jurisdiction over the IU. Therefore, due to R1 not residing in the licensed facility, this allegation is deemed 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.

Cross reports will be made to notify the appropriate parties of the concerns reported. This report was reviewed with the Interim-Administrator and a copy was provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

LIC9099 (FAS) - (06/04)

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