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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603793
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:44:17 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
04/12/2023 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20230412121230
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:0CENSUS: 0DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Facility Closed - Report Mailed to Last Known AddressTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not dispense medication as prescribed.
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 4/12/23 it was alleged that staff did not dispense medication as prescribed due to resident medications being administered late and/or not administered. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. Seven (7) out of 7 staff members interviewed expressed concerns regarding staffing, having advised that the facility staffing levels were critically low, which resulted in residents receiving medications late. Staff interviews confirmed that medications were given after the required timeframe in the computer system and instances where medication passes were completely missed due to staffing issues. (Continued on LIC9099-C P.2)
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2024
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 5
Control Number 08-AS-20230412121230
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2024
Section Cited
CCR
87465(c)(2)
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"Once ordered by the physician the medication is given according to the physician's directions." This requirement was not met, as evidenced by:
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The facility closed on 3/15/24, eliminating the potential risk to residents. A plan of corrections was not able to be made due to the facility closure.
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Based on interviews and records review, Licensee did not assure that prescribed medications were given according to the physician's directions. This posed a potential health and safety risk to residents 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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230412121230
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: 08/02/2024
NARRATIVE
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(Continued from LIC9099 p. 1)

On two occasions, via email and phone, management admitted that medication errors had occurred and that staff had been reprimanded and/or retrained to ensure that no additional medication errors occurred.

Review of Resident Council Meeting notes revealed that residents expressed concerns with medication administration at the facility. During meetings in March 2023 and April 2023, residents informed of accounts of residents being given medications late or not at all, and a resident having to forego meals due to not being able to eat until they received required medications.

Four (4) outside source interviews corroborated that residents were missing their medications and had been given medications late. Outside sources provided instances of residents not receiving their morning medications until 4:00pm and staff not adhering to a resident's pre-operation medication regimen. Additional outside sources were directly informed by residents that medications were administered late or completely missed during the timeframe of complaint.

Records review revealed that the Licensee submitted an incident report during the timeframe of complaint regarding a resident who had not received their medications for 6 days due to a miscommunication. Review of staffing schedules during the timeframe of complaint showed that in April 2023, one (1) Med Tech was scheduled for a morning shift to administer medications to all residents. This corroborated staff interviews that informed one staff member was scheduled to administer medication on all four (4) resident floors, resulting in all medications on the 4th floor being given late, after the required administration time. Resident council notes showed that during March 2023 and April 2023 meetings, residents expressed concern to staff that medications were being administered late or were completely missed.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D). A Plan of Correction was not able to be developed with the Licensee due to the facility being closed. 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 LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/12/2023 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20230412121230

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:0CENSUS: 0DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Facility Closed - Report Mailed to Last Known AddressTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Untrained staff dispensed medication to residents.
INVESTIGATION FINDINGS:
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13
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 4/12/23 it was alleged that untrained staff dispensed medication to residents. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Staff interviews did not corroborate this allegation. All staff interviewed consistently identified the training protocols for Medication Technicians (Med Tech) and confirmed that staff dispensing medications had completed their training regimen. No staff interviewed informed of observing or having knowledge of medication being given to residents by untrained staff.
(Continued on LIC9099-C p.2)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230412121230
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: 08/02/2024
NARRATIVE
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(Continued from LIC9099 p.1)

Additional staff interviews revealed that the computer system provided specific access for Med Techs that required approval only upon completion of Med Tech training. LPA directly observed the computer system used by caregivers and Med Techs during an unannounced facility visit. The options on the screen for caregivers was absent of any medication information or medication tasks. The screen for Med Techs contained options for medication administration. Based on staff interviews and LPA observations, it would not be possible for an untrained staff to view or record medication administration in the system.

Resident interviews revealed no concerns with staff qualifications for medication administration.

Records review of a Resident Council meeting during the timeframe of complaint revealed resident comments that staff treated residents well and were qualified to do their jobs.

Outside sources did not corroborate the allegation. While interviews with outside sources revealed concerns regarding low staffing and high turnover, evidence was not found regarding lack of training for Med Techs. Outside sources did not corroborate having knowledge of or observing untrained staff dispensing medications.

No records reviewed gave evidence to support that untrained staff were dispensing medication to residents.
Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is 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 LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5