374603437-3-19-2026-08-AS-SJAB-DSGV3P-20260324160500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603437
Report Date: 03/19/2026
Date Signed: 03/19/2026 12:29:06 PM

Substantiated

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
09/17/2025 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20250917154616

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: 50	DATE:	03/19/2026
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Administrator Susan O'Shaughnessy.		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident sustained a broken arm while in care

INVESTIGATION FINDINGS:

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

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. It was alleged that resident sustained a broken arm while in care. Interviews revealed on 08/12/2025 Resident 1 (R1) was in the memory care unit. Interviews revealed there were two staff on the overnight shift a caregiver and a med tech who was training a new staff. Interviews revealed while Staff 1 (S1) the med tech and trainee were upstairs, S2 (the caregiver) was downstairs covering the memory care unit. Interviews revealed that staff are supposed to do rounds every 2 hours. Interviews revealed that according to camera footage in the facility that S2 rounds began at 11:11pm, another was conducted at 3:49am and 5:28am. Interviews revealed it was at 5:28 am on 08/13/2025 that S2 conducted their rounds and observed that R1had an unwitnessed fall and was on the floor with a dried bowel movement (BM) on the side of them.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

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-20250917154616

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: 03/19/2026

NARRATIVE

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Interviews revealed that S2 called S1 on the walkie talkie told them about the incident. Camera footage showed S1 arrived at the room at 5:31am, then S1 called the lead med tech @5:37am to inform them of the incident. Interviews revealed the lead med tech told them not to move the resident, grab R1s medical book, to call 911 and call the hospital to let them know R1 was coming and that they needed a sitter. Interviews revealed that S1 relayed the message of not moving R1 to S2. Interviews revealed S1 went to the front of the facility to grab the book and make the call to 911. Interviews revealed when S1 returned to the R1s room, S1 observed R1 had been moved, showered and was dressed. Interviews revealed that camera footage shows S2 requesting towels from another staff despite R1 showing complaints of pain while their shoulder was popped out.
Interviews revealed the company policy states that rounds are to be conducted every 2 hours. It also states in the event of a witnessed or unwitnessed fall, where a resident is expressing pain, the resident must not be moved and 911 must be called immediately. EMS personnel arrived on scene at 6:03 am and took R1 to the hospital. Records reviewed revealed R1 was diagnosed with resident sustained a right humerus fracture and a small subdural hematoma. (The report shows resident suffered a right fracture humerus back in January 2025 as well and at that time they were treated non surgically) and R1 was discharged to a skilled nursing facility from the hospital. Interviews revealed the staff were written up for their actions on 08/13/2026. Interviews revealed that S1 quit after their write up and S2 was terminated on 08/20/2025 due to failure to conduct resident rounds every two hours, as required. Video footage indicated rounds were completed at 11:11 pm., 3:49 am., and 5:28 am., falling short of the mandated schedule. Improper handling of a resident following an unwitnessed fall. Despite the resident expressing pain and showing signs of a displaced shoulder, S2 proceeded to move, shower, and dress resident prior to EMT arrival and failure to adhere to emergency protocol. (The Company policy clearly states that in the event of a witnessed or unwitnessed fall accompanied by pain, the resident must not be moved and 911 must be called immediately. These actions represent a serious breach of our standards of care and safety protocols and compromise the well-being of our residents).

Based on interviews, and records review, the allegation is valid, and the preponderance of the evidence has been met. 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: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20250917154616

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/02/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to schedule an in-service training on the topics of care and supervision and protocols for staff by an outside source.Licensee will send proof of training, training materials and sign in sheet to CCL by POC due date of 04/02/2026
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not ensure that R1 was provided care and supervision, which posed an immediate health, safety, and personal rights risk to 1 (R1) of 41 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC9099 (FAS) - (06/04)

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