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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603793
Report Date: 05/31/2023
Date Signed: 05/31/2023 02:06:17 PM


Document Has Been Signed on 05/31/2023 02:06 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SUNRISE OF SABRE SPRINGSFACILITY NUMBER:
374603793
ADMINISTRATOR:JESSICA ZEPEDAFACILITY TYPE:
740
ADDRESS:12515 SPRINGHURST DRTELEPHONE:
(858) 391-9160
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:100CENSUS: 73DATE:
05/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Executive Director Kimberly SantillianTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced, subsequent Case Management visit to cite deficiencies. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Kimberly Santillian.

Today's continuation visit was in response to three (3) SOC341 Report of Suspected Dependent Adult/Elder Abuse forms, which licensee self-submitted to the CCLD San Diego Regional Office (received on 04/05/2023). The first SOC341 described a received allegation that Staff #1 (S1) yelled at Resident #1 (R1) on two separate occasions. [See LIC 811 Confidential Names List pages for a description of person identifiers used in this report.] The second SOC341 described a received allegation that S1 grabbed Resident #2’s (R2’s) face on one occasion and struck R2’s face on another occasion. The third SOC341 described a received allegation that S1 gave Resident #3 (R3) a cold shower as punishment. Per the three SOC341’s: each of these events occurred on unknown days between mid-February 2023 and mid-March 2023, and there were no known injuries to the involved residents.

During CCLD’s prior visit, LPA performed a welfare check, verifying that R1, R2, and R3 were safe and uninjured, as were their peers in the facility's memory care unit. During today’s visit, LPA collected copies of additional resident and employee records, and interviewed relevant staff.

[CONTINUED ON LIC 809-C, 1 of 2]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SUNRISE OF SABRE SPRINGS
FACILITY NUMBER: 374603793
VISIT DATE: 05/31/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

Per staff interview and records: Staff #2 (S2) witnessed S1 yell at R1 on one occasion and intervened to stop and separate S1 from R1. Staff #3 (S3) witnessed S1 yell at R1 on a separate occasion and intervened to stop and separate S1 from R1. S2 and S3 each reported their respectively witnessed incidents to supervisor Staff #4 (S4); S4 confirmed receiving both of those reports. S2 also witnessed S1 yell at Resident #4 (R4), causing R4 to visibly tremble. [During the welfare check, LPA verified that R4 was safe and uninjured.] S2 stated they reported this incident (involving R4) to S4, but S4 denied knowing. Staff #5 (S5) stated that S2 told them about this incident against R4, and that S2 said they had prior notified S4 about it. Staff #6 (S6) described a different occasion when they themselves were yelled at by S1 in front of multiple residents, causing residents to verbalize/show discomfort.

Staff interview and records further revealed: On one occasion, S2 witnessed S1 place their hand on R2’s face to try to stop them from yelling. On another occasion, S2 witnessed S1 slap R2’s face with an open hand. S2 said they later told S4 about these incidents, but S4 denied knowing. S5 stated that S2 told them about these incidents against R3, and that S2 said they had prior notified S4 about them.

Staff interview and records further revealed: On one occasion, S2 witnessed S1 give R2 a cold shower as punishment following an incontinence episode. R1 screamed, but S2 did not stop S1 during the shower or ask other coworkers for help during the incident itself. S2 stated they later reported this incident to S4; S4 confirmed receiving this report.

Due to their baseline cognitive impairment and memory loss, R1, R2, R3, and R4 were each unable to participate as a reliable historian/interviewee for this case. According to their latest respective LIC602 Physician’s Reports: R1, R2, R3, were each diagnosed with dementia, while R4 was diagnosed with Mild Cognitive Impairment.

Per staff interviews and records: the facility administrator learned of the above incidents on 04/03/2023, which was multiple weeks after the timeframe that they occurred. Licensee suspended both S1 and S4’s employment on 04/03/2023, pending internal investigation. [CONTINUED ON LIC 809-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SUNRISE OF SABRE SPRINGS
FACILITY NUMBER: 374603793
VISIT DATE: 05/31/2023
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2] Regarding reports of S1’s actions against R2 and R3, the facility administrator themselves notified CCLD, the San Diego County Long Term Care Ombudsman (LTCOP), and local law enforcement. They also phoned the responsible parties for R2 and R3, but not the responsible party for R1 and R4. Multiple other staff knew of abuse but did not themselves meet their individual Mandated Reporting Requirements, which contributed to Licensee overall not meeting reporting requirement deadlines. As of LPA’s initial 05/30/2023 visit, Licensee had not yet notified CCLD about S1 yelling at R4, despite records proving that Licensee had constructive knowledge of this allegation on 04/03/2023. Additionally, Licensee had not provided copies of the written reports to the responsible parties of R1, R2, R3, and R4, as was required. Upon the conclusion of its own investigation, Licensee terminated both S1 and S4’s employment.

A preponderance of evidence exists to show: a) through S1’s actions, licensee did not ensure R1 and R4 were treated with dignity by its staff; b) through S1’s actions, licensee did not ensure R2 and R3 were free from physical abuse and/or punishment; and, c) Licensee did not meet reporting requirements.

Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction was jointly developed with the licensee.

An exit interview was conducted with Santillian, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/31/2023 02:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: SUNRISE OF SABRE SPRINGS
FACILITY NUMBER: 374603793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2023
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff...”
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According to employee records: S1’s employment was suspended on 04/03/2023, and terminated on 04/07/2023. On 04/13/2023, licensee retrained its larger staff team on Mandated Reporting requirements, and on 04/17/2023 and 04/18/2023, licensee retrained its larger staff team on how to appropriately respond to resident behaviors. These actions resolved the immediate risk, such that the deficiency can be cleared. Licensee agreed to use a third-party source to retrain its staff on Resident’s Personal Rights (87468.1 and 87468.2), and to E-mail the training sign-in sheet to LPA by 06/30/2023.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff (S1) did not treat 2 of 73 residents (R1 and R4) with dignity, which posed an immediate personal rights risk to persons in care.
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Type A
06/01/2023
Section Cited
CCR87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment… abuse…” This requirement was not met, as evidenced by:
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According to employee records: S1’s employment was suspended on 04/03/2023, and terminated on 04/07/2023. On 04/13/2023, licensee retrained its larger staff team on Mandated Reporting requirements, and on 04/17/2023 and 04/18/2023, licensee retrained its larger staff team on how to appropriately respond to resident behaviors. These actions resolved the immediate risk, such that the deficiency can be cleared. Licensee agreed to use a third-party source to retrain its staff on Resident’s Personal Rights (87468.1 and 87468.2), and to E-mail the training sign-in sheet to LPA by 06/30/2023.
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Based on records and interviews, licensee’s staff (S1) did not ensure that 2 of 73 residents (R2 and R3) were free from punishment and/or abuse, which posed an immediate health, safety, and 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/04/2024 09:17 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/01/2023 11:30 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: SUNRISE OF SABRE SPRINGS
FACILITY NUMBER: 374603793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
87211(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…below: (D) Any incident which threatens the welfare…of any resident, such as psychological abuse of a resident by staff…”
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As of the date of the deficiency issuance, licensee had sent copies of LIC624 Incident Reports pertaining to the incidents affecting R1, R2, R3, and R4, to each of their respective responsible parties. Licensee also provided CCLD with an SOC341 and an LIC624 for the incident affecting R4. These actions resolve the deficiency.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee did not submit a written report the licensing agency and the person responsible within seven days of the occurrence of an incident which threatened resident welfare for 4 of 73 residents (R1, R2, R3, and R4), which posed a potential health, safety, and 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5