374603437-2-20-2026-08-AS-APAO-DRLVLZ-20260224153247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603437
Report Date: 02/12/2026
Date Signed: 02/20/2026 04:16:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2025 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20250904133832

FACILITY NAME:	SUNGARDEN TERRACE		FACILITY NUMBER:	374603437
ADMINISTRATOR:	SUSAN O'SHAUGHNESSY		FACILITY TYPE:	740
ADDRESS:	2045 SKYLINE DRIVE		TELEPHONE:	(619) 462-5831
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY:	110	CENSUS: 47	DATE:	02/12/2026
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Susan O'Shaughnessy Administrator		TIME COMPLETED:	04:19 PM

ALLEGATION(S):

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The facility did not provide enough staff for adequate resident care.
Unqualified Facility staff administered medications to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Administrator Susan O'Shaughnessy.

On 9/4/25 it was alleged that the Licensee did not provide enough staff for adequate resident care. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Interviews were conducted with three staff members, three residents, and three outside sources. All staff reported that staffing assignments are posted daily and coverage is sufficient to meet resident needs, including assistance with ADLs, medication administration, and timely call-light response.

(Continued on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

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 08-AS-20250904133832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/12/2026

NARRATIVE

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(Continued from LIC9099C 3 of 3)

MARs reviewed showed medications administered as prescribed, with no discrepancies noted. Incident and complaint logs for the past six months contained no substantiated reports of medication errors or unqualified staff administering medications.

LPA observations during the visit confirmed that medications were stored securely in locked cabinets and carts, and medication passes were conducted by staff wearing name badges indicating their role. No unqualified staff were observed handling medications.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Susan O'Shaughnessy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20250904133832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/12/2026

NARRATIVE

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(Continued from LIC9099 2 of 3)

Residents confirmed that care is provided as scheduled, call-light response is prompt, and no delays have impacted their safety or comfort. Outside sources, including a family member, hospice nurse, and ombudsman, stated they observed adequate staff presence and timely care delivery, with no concerns regarding staffing adequacy.

Records reviewed included staffing schedules, timecards, call-light response reports, resident service plans, medication administration records, and incident logs for the past six months. Documentation showed scheduled coverage consistent with resident needs and no substantiated complaints related to staffing.

LPA observations during the visit confirmed staff were present and actively assisting residents with ADLs and mobility. Call-light spot checks demonstrated responses within three to six minutes, and no unattended residents or signs of unmet care needs were observed.

On 9/4/25 it was alleged that unqualified facility staff administered medications to the residents. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Interviews were conducted with three staff members, three residents, and three outside sources. All staff interviewed stated that only trained and authorized personnel administer medications, and confirmed they have completed required medication training per facility policy and Title 22 requirements. Staff reported that medication administration is documented in the Medication Administration Record (MAR) and overseen by supervisory staff. Residents interviewed stated they receive medications on time and have not observed or experienced untrained staff giving medications. Outside sources, including a family member, hospice nurse, and ombudsman, reported no concerns regarding medication administration practices and confirmed that medications appear to be managed appropriately.

Records reviewed included staff training logs, medication competency checklists, medication technician certificates, MARs, and facility policies on medication administration. Documentation confirmed that staff assigned to medication duties have completed required training and competency evaluations in accordance with regulations.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

LIC9099 (FAS) - (06/04)

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