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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403516
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:27:02 PM


Document Has Been Signed on 05/04/2023 01:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SUN CITY GARDENSFACILITY NUMBER:
336403516
ADMINISTRATOR:BITUIN D GARCIAFACILITY TYPE:
740
ADDRESS:28500 BRADLEY ROADTELEPHONE:
(951) 679-2391
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:0CENSUS: 66DATE:
05/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Robyn Rebollar, AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit in relation to complaint #18-AS-20230428100816. LPA met with Administrator Robyn Rebollar and explained the purpose of the visit. LPA then toured the facility.

During the complaint investigation, LPA found that Resident 1 (R1) had fallen on January 23, 2023. Through record review, LPA found that the Licensee did not report the fall to the Department. The facility was cited per Title 22.

An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811, LIC809-D, and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/04/2023 01:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SUN CITY GARDENS
FACILITY NUMBER: 336403516

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2023
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports..(1) A written report shall be submitted to the licensing agency (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident..This requirement was not being met as evidenced by:
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Licensee to submit the Unusual Incident Report regarding R1, and their fall by POC date. Additionally, Licensee to conduct in-service training with staff on the cited regulation by POC date.
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Through interview, LPA determined that the Licensee did not report to the Department that R1 had a fall that occurred on 01/23/2023. This poses a potential health and safety risk to 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.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2