374603793-7-26-2024-08-AS-JLOT-D7MNBT-20240729101938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603793
Report Date: 07/18/2024
Date Signed: 07/26/2024 12:52:36 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
01/03/2023 and conducted by Evaluator Nacole Patterson

COMPLAINT CONTROL NUMBER: 08-AS-20230103100232

FACILITY NAME:	SUNRISE OF SABRE SPRINGS		FACILITY NUMBER:	374603793
ADMINISTRATOR:	JESSICA ZEPEDA		FACILITY TYPE:	740
ADDRESS:	12515 SPRINGHURST DR		TELEPHONE:	(858) 391-9160
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	0	CENSUS: 0	DATE:	07/18/2024
		UNANNOUNCED	TIME BEGAN:	08:16 PM
MET WITH:	Facility Closed - Report Mailed to Last Known Address		TIME COMPLETED:	09:20 PM

ALLEGATION(S):

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Staff did not meet the care needs of residents.

INVESTIGATION FINDINGS:

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The following determination of findings has been made by Licensing Program Analyst (LPA) Nacole Patterson regarding the above allegation. The facility closed on 3/15/24 due to a change of ownership, and this report was mailed to the last known address on record for the former Licensee regarding the findings.

On 1/3/23 it was alleged that staff did not meet the care needs of residents. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, and interviews with facility staff and outside sources. Five (5) of five (5) staff interviews corroborated the allegation, staff informed that they had experienced ratios of one (1) staff to thirty-three (33) residents which included residents who required 2-person transfers. Caregivers stated they observed twenty (20) to forty (40) minute wait times for residents and caregivers were pulled from caregiving duties to assist in the dining room due to lack of dining room staff. Staff further informed that residents had received their medications outside of the required administration timeframe or not at all due to too few Medication Technicians scheduled to administer medications. (Continued on LIC9099-C p.2)
This is an amended report.

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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 4

Control Number 08-AS-20230103100232

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: SUNRISE OF SABRE SPRINGS	FACILITY NUMBER: 374603793
	VISIT DATE: 07/18/2024

NARRATIVE

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(Continued from LIC9099 p.1)

Staff further informed that the medication administration delays resulted in residents missing meals because their prescriptions were required before they could eat.

Outside source interviews corroborated the allegation, informing that the facility was critically understaffed due to high turnover, which resulted in resident needs not being met. Outside source interviews further informed that numerous residents had expressed concern to management in Resident Council Meetings regarding long wait times for caregiver and medication assistance. Outside sources corroborated staff statements that caregivers were being taken from resident floors to work in the dining room during meals. An outside source directly observed a resident who had been waiting for two (2) hours for a caregiver to return to assist them because they were unable to walk on their own. Additional outside sources informed of instances of residents waiting thirty (30) minutes for assistance after pressing their pendant, and instances where only one caregiver was working the Memory Care unit, which was two (2) floors.

Records review of Resident Council Meeting notes revealed that residents expressed concern to management regarding long wait times for pendant calls, food service, and medications at three resident council meetings during the timeframe of December 2022, and March through April 2023.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies and Plan of Corrections were unable to be created due to the facility no longer being in operation. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the last known address on file for the facility.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
01/03/2023 and conducted by Evaluator Nacole Patterson

COMPLAINT CONTROL NUMBER: 08-AS-20230103100232

FACILITY NAME:	SUNRISE OF SABRE SPRINGS		FACILITY NUMBER:	374603793
ADMINISTRATOR:	JESSICA ZEPEDA		FACILITY TYPE:	740
ADDRESS:	12515 SPRINGHURST DR		TELEPHONE:	(858) 391-9160
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	0	CENSUS: 0	DATE:	07/18/2024
		UNANNOUNCED	TIME BEGAN:	08:16 PM
MET WITH:	Facility Closed - Report Mailed to Last Known Address		TIME COMPLETED:	09:20 PM

ALLEGATION(S):

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Facility did not follow reporting requirements of an unusual incident.

INVESTIGATION FINDINGS:

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The following determination of findings has been made by Licensing Program Analyst (LPA) Nacole Patterson regarding the above allegation. The facility closed on 3/15/24 due to a change of ownership, and this report was mailed to the last known address on record for the former licensee regarding the findings.

On 1/3/23 it was alleged that the facility did not follow reporting requirements of an unusual incident of a positive Covid-19 case. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, and interviews with facility staff and outside sources. The reporting party informed that they had no concerns regarding the allegation, and advised that the allegation was submitted in error. Staff interviews revealed no concerns regarding reporting requirements and described consistent protocols for when Covid-19 cases occurred at the facility. The facility submitted an Infection control Plan to the Department on 6/27/22. Review of additional Licensee submissions to the Department revealed that the facility reported Covid-19 cases and unusual incidents as required. (Continued on LIC9099-C p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20230103100232

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: SUNRISE OF SABRE SPRINGS	FACILITY NUMBER: 374603793
	VISIT DATE: 07/18/2024

NARRATIVE

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(Continued from LIC9099 p.1)

No records were found to corroborate the allegation that the Licensee did not report Covid-19 cases or other required incidents to the proper agencies.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the last known address on file for the facility.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4