374603437-8-18-2025-08-AS-SJAB-DKZTN3-20250829145203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603437
Report Date: 08/18/2025
Date Signed: 08/18/2025 05:00:40 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
06/20/2025 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20250620154824

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: 42	DATE:	08/18/2025
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator Susan O'Shaughnessy		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff neglected residents care needs
Licensee did not uphold visitor policy.
Staff took away residents cell phone.

INVESTIGATION FINDINGS:

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

Department’s investigation consisted of staff and resident interviews, interviews with outside sources and LPA observations in the memory care area of the facility.

On June 20, 2025, Community Care Licensing (CCL) received a complaint alleging that staff neglected the care needs of Resident #1 (R1). More specifically R1 has lost a lot of weight recently and was itching. Hospice records indicated R1 has diagnoses including dementia, lung mass, and congestive heart failure, with documented periods of agitation and refusal of care. During the visit, LPA observed R1 being offered multiple food options and staff encouraging them to eat. R1 declined some items but accepted others, but ate very little. No visible signs of itching were observed. Interviews with outside sources and LPA observations reveal staff were attentive and present. (Continued on LIC9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

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-20250620154824

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: 08/18/2025

NARRATIVE

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(Continued from LIC9099)

It was also alleged that the licensee did not uphold the facility’s visitor policy. Interviews with an outside source revealed that two visitors attempted to visit R1 while appearing intoxicated. Staff spoke with the visitors and requested that they contact R1’s responsible person. The visitors subsequently left the facility. LPA interviews confirmed that visits on later dates did occur, during which the reporting party was able to enter the facility without issue, and the visits went well.

It was also alleged that staff took away R1’s cell phone. LPA interview with reporting party was unclear if facility took the phone and stated it was unclear who took it. A review of R1's inventory at move-in did not list a cell phone, and both R1's responsible person confirmed R1 no longer has a phone due to their inability to use it. No documentation or credible evidence was found to support the claim that the facility removed or withheld a cell phone.

Based on interviews, and LPA observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated.

An exit interview was conducted with Executive Director Susan O'Shaughnessy, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

LIC9099 (FAS) - (06/04)

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