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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603437
Report Date: 04/23/2026
Date Signed: 04/23/2026 03:55:18 PM

Document Has Been Signed on 04/23/2026 03:55 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
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: 45DATE:
04/23/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Administrator Susan O'ShaugnessyTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Susan O'Shaugnessy.

Facility internal incident reports and progress notes, combined with hospice visit records and interviews of managers and outside sources, aligned to show: Resident #1’s (R1’s) terminal/admitting hospice diagnoses were “unspecified severe protein-calorie malnutrition” and “Alzheimer’s disease with late onset.” [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] R1 had an unwitnessed fall inside their bedroom on the evening of 03/31/2026, after which facility staff phoned R1’s responsible person (RP) and hospice agency. Per hospice notes, facility staff reported to hospice personnel that R1’s left elbow following the fall had redness, swelling, and pain with movement. A hospice nurse visited and assessed R1 that same evening, writing, “[R1’s] left elbow noted to be significantly swollen, red, warm to touch, and tender compared to right elbow…pain evidenced by grimacing and guarding left elbow.” The hospice nurse stated to facility staff that they believed R1’s left arm to have a fracture and recommended that R1 be sent to the hospital. However, R1’s responsible person did not want R1 sent to the hospital.

Licensee deferred to the RP and did not call 911 for R1, which is still required when there is a medical emergency not directly related to the expected course of the resident’s terminal illness. (Per regulation, Licensees are required to call 911 in these situations. If a resident and their RP still refuse transport to the hospital, then they should do so directly to the first responders, after those first responders have evaluated the resident on scene and provided their own recommendations). [CONTINUED ON LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2026
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: 04/23/2026
NARRATIVE
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[CONTINUED FROM LIC 809] Licensee’s own internal written policy titled “Medical Emergency” states, “The Administrator or caregivers are not required to obtain permission from the family/responsible party before summoning emergency medical services.” R1 remained at the facility through 04/04/2026, during which time Licensee did not seek or arrange for mobile X-ray to be performed on R1’s arm. R1 then passed away at home on 04/10/2026. Per the hospice agency, R1’s cause of death was “Alzheimer’s Dementia.”

Licensee also did not submit an LIC624 Incident Report (or equivalent written report) to CCLD or R1’s RP, describing R1’s fall and symptoms. (Regulation requires such a written report to be submitted to both CCLD and the RP within seven days of incident occurrence.)

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee. LPA also provided Technical Assistance regarding CCLD’s interpretation of a resident’s right to privacy (refer to the LIC 9102-TA page).

An exit interview was conducted with Administrator Susan O'Shaugnessy, to whom a copy of this report, the LIC 809-D page, the LIC9102-TA page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2026 03:55 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/23/2026 at 02:22 PM
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: 04/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2026
Section Cited
CCR
87469(c)(3)

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87469 Advanced Directives and Requests Regarding Resuscitative Measures: “(c)(3) Specifically for a terminally ill resident that is receiving hospice services…For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” This requirement was not met, as evidenced by:
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Licensee agreed to conduct in-service retraining for current staff on Licensee’s existing “Medical Emergency” written policy and regulations CCR 87465 and 87469. (The texts of these regulations were provided to the administrator during today’s visit.) Licensee agreed to E-mail a copy of the training sign-in to LPA, by the POC due date.
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Based on records and interviews, when 1 of 45 residents (R1), who was receiving hospice services, experienced a medical emergency not directly related to the expected course of their terminal illness, Licensee did not immediately telephone emergency response (9-1-1) for them. This posed a potential health risk to persons in care.
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Type B
04/30/2026
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements: “(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified…(D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by:
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During today’s visit, LPA provided the facility administrator training on LIC624 Incident Reports and the full text of CCR 87211. Licensee agreed to write an LIC624 Incident Report describing their current knowledge regarding R1’s fall on 03/31/2026, and to E-mail a copy of this to both R1’s RP and CCLD (CCLASCPSanDiegoRO@dss.ca.gov), bcc’ing LPA on both E-mails, by the POC due date.
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Based on records and interviews, 1 of 45 residents (R1) experienced an incident which threatened their welfare and/or health, and Licensee did not submit a written report to the licensing agency and the resident’s responsible person within seven days. This posed a potential personal rights risk to persons 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:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2026


LIC809 (FAS) - (06/04)
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