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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603437
Report Date: 08/25/2025
Date Signed: 08/26/2025 10:30:14 AM

Document Has Been Signed on 08/26/2025 10:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SUNGARDEN TERRACEFACILITY NUMBER:
374603437
ADMINISTRATOR/
DIRECTOR:		SUSAN O'SHAUGHNESSYFACILITY TYPE:
740
ADDRESS:2045 SKYLINE DRIVETELEPHONE:
(619) 462-5831
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 110CENSUS: 44DATE:
08/25/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Susan O'Shaughnessy AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management - Incident visit. LPA was welcomed by Susan O'Shaughnessy, the Director of Marketing and Admissions, and discussed the purpose of the visit.

Today's visit was in response to an Incident Report (LIC624) that the licensee self submitted to the CCLD San Diego Regional Office. According to the LIC624, on 8/21/24, Resident #1 (R1) was involved in an incident where a Staff 1 (S1) had a physical altercation with R1.

The video shows R1 and S1 hitting and pushing each other. R1 falls to the ground and crawls on the floor until they can get up, while S1 watched and does not assist R1. R1 is seen on the video wiping blood from their hand.  R1 tries to stop the bleeding with a tissue, while they bend over to wipe the blood from the floor.  Staff 2 (S2) came to the memory care unit, where they saw the cut on R1's hand and applied aid.

R1 was taken to the emergency room, where the resident received four stitches.The facility did not notify R1's responsible party of the incident.  

During today’s visit, LPA performed a facility tour,  welfare check, collected records, observed R1, and interviewed staff.

(Continued on LIC809C)
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Amy Domingo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SUNGARDEN TERRACE
FACILITY NUMBER: 374603437
VISIT DATE: 08/25/2025
NARRATIVE
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(Continued from LIC809)

Two (2) deficiencies were cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Administrator.

Pursuant to the California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached LIC809D.  An immediate Civil penalty of $500 was assessed during today's visit for the facility's: To be free from punishment, humiliation, intimidation, abuse, or other actions, and the licensee shall provide for and encourage all personnel to report observations or evidence of such abuse.

An exit interview was conducted with Administrator, to whom a copy of this report, the LIC809-D, the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Amy Domingo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2025 10:30 AM - It Cannot Be Edited


Created By: Amy Domingo On 08/25/2025 at 11:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNGARDEN TERRACE
FACILITY NUMBER: 374603437

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2025
Section Cited
CCR
87468.1(a)(3)

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To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

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LPA and facility administration jointly agreed to have all staff in serviced regarding Resident Rights by 9/8/25
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This requirement was not met, as evidenced by: Interviews and records review for 1 of 44 residents

This poses an immediate health risk to residents in care.
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Type A
09/08/2025
Section Cited
CCR87413(a)(3)

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Residents in all residential care facilities for the elderly shall have all of the following personal rights: The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation or prejudice.
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LPA and facility administration jointly agreed to have all staff in serviced regarding Personnel Reporting requirements by 9/8/25
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This requirement was not met, as evidenced by interviews and records review for 1 of 44 residents.

This poses an immediate health 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Domingo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2025


LIC809 (FAS) - (06/04)
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