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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881358
Report Date: 04/15/2024
Date Signed: 04/15/2024 05:23:21 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
02/26/2024 and conducted by Evaluator Jacqueline Shaw Ross
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240226164235
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: 64DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
04:29 PM
MET WITH:Barbara Guzman, Business Office ManagerTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident.
Resident was exposed to hazardous gas while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to deliver findings for the allegations noted above. LPA met with Barbara Guzman, Business Office Manager and explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews, and records review.

On 2/26/2024, Community Care Licensing received an complaint alleging staff did not seek medical attention for a resident, and that resident was exposed to hazardous gas while in care.

The LPA conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. LPA was provided with the roster for the facility. A review of the resident roster and face sheet indicted that the resident lives in the independent living section of the facility and that CCLD does not have jurisdiction over the independent living units of the facility. Therefore, this complaint is unfounded. A cross report will be made to the appropriate departments who have jurisdiction. This agency has investigated the complaint alleging, Staff did not seek medical attention for resident, and that resident was exposed to hazardous gas while in care. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the Business Office Manager, Barbara Guzman.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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 2
Control Number 18-AS-20240226164235
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: 04/15/2024
NARRATIVE
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SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2