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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881358
Report Date: 08/29/2024
Date Signed: 08/29/2024 01:54:36 PM

Substantiated


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
05/15/2024 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20240515150339
FACILITY NAME:SUN CITY GARDENSFACILITY NUMBER:
331881358
ADMINISTRATOR:DIANE DOMINGOFACILITY TYPE:
740
ADDRESS:28500 BRADLEY ROADTELEPHONE:
(951) 679-2391
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:74CENSUS: 63DATE:
08/29/2024
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Diana Domingo - Executive DirectorTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility staff did not dispense medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Executive Director Diana Domingo and Resident Service Director Bituin Garcia and explained the purpose of the visit. Complaint investigation consisted of a tour of the interior/exterior areas of the facility, interviews, and records review of requested pertinent documents.

Regarding the allegation “Facility staff did not dispense medications as prescribed” it was reported Resident One (R1) has not been receiving their medication for months. Interview with Staff One (S1) revealed the facility received a new medication order for R1 that had a change of dosage from 500mg to 200mg and staff had requested clarification of correct dosage for R1’s medication on 06/29/2023. Staff received a medication list from R1’s physician dated 08/28/2023 with R1’s medication with a dosage of 200mg and orders to take orally twice a day.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
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 18-AS-20240515150339
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: 08/29/2024
NARRATIVE
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Records review of R1’s MAR revealed a note entered by Staff Two (S2) for R1’s medication with instructions “TAKE 1 CAPSULE BY MOUTH TWICE DAILY **NEED TO CLARIFY ORDER – IS WRITTEN AS 200MG” with a Start Date set at 09/08/2023 with an End Date 09/08/2023. Records review of R1’s Medication Administrator Record (MAR) revealed on 10/13/2023 staff stopped administering the medication with a 500mg dosage to R1 with a written in note “Change of Order”. Records review of R1’s MAR after 10/13/2023 did not have R1’s prescribed medication with a dosage of 200 mg with orders to take twice daily. Interview with Staff Three (S3) revealed staff will only give mediation that is listed on the MAR and the prescribed medication was not given to R1.

Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to Garcia,
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20240515150339
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care: (a) ... shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met by:
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Licensee implemented a plan to conduct weekly medication audits for the residents in care. Licensee will communicate with Yorba Linda Pharmacy to conduct quarterly audits of the residents medication. Licensee will send LPA confirmation of weekly audit by Plan of Correction date 09/13/2024.
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Based on interviews and record review, the Licensee did not comply with the above regulation with resident one (R1). Medications for R1 were not administered as prescribed. This is a potential health and safety risk for R1 and other residents 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: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3