331881358-7-5-2023-18-AS-JDHS-CTMUXK-20230711155828

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881358
Report Date: 07/05/2023
Date Signed: 07/05/2023 04:55:36 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
06/28/2023 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230628103119

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: 64	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	04:19 PM
MET WITH:	Diane Domingo, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff did not provide resident's responsible party a 60 day written notice of a new charge at the facility.
Facility staff did not include new charges in resident's admission agreement.

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 Administrator, Diane Domingo, and informed her of the purpose for her visit.
The investigation included staff/resident interviews, records review, and receipt of relevant documentation. A report was received alleging the facility did not provide the responsible party of Resident One (R1) a 60-day written notice for a rate change or document of the change in a new admission agreement. Staff interviews reported R1 was a resident of the Independent Living Unit (IU) of Sun City Gardens, which is owned by the same corporation. The unit, though, is not licensed by the Department. A review of the Resident Roster revealed R1 was not listed as a resident of the Licensed facility. Therefore, due to R1 not residing in the licensed facility and the Department not having jurisdiction over the IU, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means 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 Administrator and a copy was provided.

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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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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