374603437-4-17-2025-08-AS-SJAB-DG8UVM-20250430155522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603437
Report Date: 04/17/2025
Date Signed: 04/17/2025 05:58:15 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
04/14/2025 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20250414103911

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: 12	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator Susan O'Shaughnessy,		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Licensee staff did not take steps to prevent the spread of a communicable disease.
Licensee staff does not ensure residents receive adequate medical treatment.

INVESTIGATION FINDINGS:

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

On April 14, 2025, Community Care Licensing (CCL) received a complaint alleging that licensee staff did not take steps to prevent the spread of a communicable disease and licensee staff does not ensure residents receive adequate medical treatment. The Department’s investigation consisted of staff and resident interviews, interviews with outside sources, and a facility tour of common areas and resident rooms in the memory care area of the facility.

Regarding the allegation, licensee staff did not take steps to prevent the spread of a communicable disease. More specifically, residents were experiencing scabies symptoms in February 2025 and continued to exhibit symptoms of scabies in April 2025. (Continued on LIC 9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250414103911

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: 04/17/2025

NARRATIVE

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(Continued form 9099) Staff interviews revealed that they have not witnessed other residents itching in a manner that would make them suspicious of Scabies. Staff interview revealed that facility staff enacted infection control protocols upon receiving notice of a possible Scabies case at the facility. Staff interview revealed that all staff were briefed and trained on infection control protocols and management was made aware of any potential scabies case as soon as it was observed. Staff interview revealed that they have been thoroughly cleaning, sanitizing and changing the sheets daily in the suspected room as utilizing PPE during the time frame of the complaint. Staff interviews further reveal the linens and clothing are being properly laundered or disinfected. The Administrator did confirm that the facility had not reached outbreak status for Scabies during the time frame of the complaint.

Regarding the second allegation, licensee staff does not ensure residents receive adequate medical treatment. More specifically, from February 2025 to April 2025 Resident #1(R1) has had no visible improvements. Staff and outside source interviews reveal that the treatment for C1 was being followed as prescribed. Staff members interviewed consistently described the administration instructions of the medication in question. Interview with outside sources reveal no concerns or knowledge of errors regarding medication administration. They also reveal the facility has been in communication with the responsible party as well as working with medical agencies on C1's behalf.

Staff interview further revealed that the official notification protocol was not enacted because an outbreak had not been determined, but staff were provided information on scabies symptoms. Outside source interview revealed no concerns regarding the Licensee's infection control notification protocols. Records review did not show that the Licensee has failed to report confirmed outbreaks to necessary parties and agencies when required.

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

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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