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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604350
Report Date: 03/18/2026
Date Signed: 03/18/2026 07:51:15 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
11/25/2025 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20251125133020
FACILITY NAME:SUNSET COAST ASSISTED LIVINGFACILITY NUMBER:
374604350
ADMINISTRATOR:KARINA LOPEZFACILITY TYPE:
740
ADDRESS:1697 DONAX AVETELEPHONE:
(619) 882-5003
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY:6CENSUS: 6DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Licensee, Patricia TapiaTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff did not protect resident from verbal abuse
INVESTIGATION FINDINGS:
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On March 18, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver the findings regarding the above-referenced allegation. LPA was greeted by Staff Betty Valdez. LPA Garcia-Centeno met with Licensee Patricia Tapia via telephone to discuss the investigative findings.

The Department’s investigation included facility observations, record reviews, and interviews with staff, residents, responsible parties, and outside sources.

On November 25, 2025, Community Care Licensing (CCL) received a complaint alleging that staff did not protect Resident 1 (R1) from verbal abuse by Resident 2 (R2). The complaint alleged that R2 had been verbally aggressive toward R1 for an extended period of time and that staff intervention had not been sufficient to stop the behavior.

(Continue at LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026
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 6
Control Number 08-AS-20251125133020
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: SUNSET COAST ASSISTED LIVING
FACILITY NUMBER: 374604350
VISIT DATE: 03/18/2026
NARRATIVE
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(Continue from LIC9099)

The reporting party indicated the situation had been ongoing for several months and was causing emotional distress to R1. Staff were provided the LIC811 Confidential Names to identify R1 and R2.

During the investigation, LPA conducted multiple visits to the facility and interviewed residents, staff, and outside sources who provided consistent accounts regarding R2’s behavior toward R1. Records reviewed during the investigation confirmed that R2 has diagnoses including dementia, confusion/disorientation, and aphasia, and has a documented history of aggressive and impulsive behaviors. Admission records showed that R1 has resided at the facility since December 2020 and that R2 was admitted in September 2023. Facility records indicated that R2 experienced a change in condition beginning around July 2025 and that staff and R2’s medical providers have been addressing behavioral symptoms related to dementia, including medication adjustments.

During an interview conducted on December 3, 2025, R1 reported that R2 frequently yells and curses in Spanish toward R1 for no apparent reason. R1 stated that R2 becomes angry when R1 performs normal activities such as turning on the bedroom light, watching television, or speaking on the telephone. R1 reported that R2 uses profanity and threatening language, including statements instructing R1 to leave the room. R1 stated that due to the verbal aggression, R1 often leaves the bedroom and sits in the living room to avoid confrontation. R1 reported that staff frequently instruct R1 to leave the room when R2 becomes upset, rather than redirecting or removing R2. R1 stated that R1 feels unable to freely use the bedroom, television, or personal space due to R2’s behavior and reported considering moving from the facility because the living environment no longer feels comfortable.

R1 also reported a physical incident in which R2 threw a water bottle in R1’s direction while yelling and cursing. R1 reported that the bottle was thrown while R1 was seated on the bed getting dressed. Although no injury was reported, the act of throwing the object caused concern and contributed to fear that the situation could escalate.


(Continue at LIC9099D)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20251125133020
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: SUNSET COAST ASSISTED LIVING
FACILITY NUMBER: 374604350
VISIT DATE: 03/18/2026
NARRATIVE
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(Continue from LIC9099C)

Staff interviews corroborated R1’s statements regarding ongoing verbal aggression. Staff confirmed that R2 frequently directs profanity toward R1, including derogatory and aggressive language in Spanish. S1 stated that R2 “does not like R1” and that R1 is often the target of R2’s outbursts. S1 further reported that R2’s behavior worsened around November 2025 and that R2 frequently yelled at R1 using profanity and other offensive language.
Staff also confirmed the water bottle incident, reporting that on or about November 25, 2025, at approximately 6:45 a.m., R2 became angry when R1 turned on the bedroom light while getting dressed. According to staff, R2 began yelling at R1 and threw a water bottle toward R1 while cursing. Staff reported that the bottle did not strike R1 and that no injuries were observed. However, the incident demonstrates an escalation from verbal aggression to physical behavior directed toward R1. Staff reported that incidents involving R2’s aggression were documented in the facility’s electronic documentation system and had been reported to the Administrator. Records review confirmed the documentation.

Additional staff interviews confirmed that when R2 becomes verbally aggressive, staff intervene by separating the residents, typically by asking R1 to leave the bedroom and sit in the living room while R2 remains in the shared room. Staff indicated this approach is used because R2 becomes more agitated if asked to leave the room. Staff reported that R2 has previously struck caregivers and can become difficult to manage during outbursts.

Interviews with other residents living in the facility further corroborated the presence of ongoing verbal aggression by R2 toward R1. Resident 3 stated that R2 frequently yells loudly at R1 and that the yelling can be heard from other areas of the home. Resident 4 reported that R2 “yells and screams all the time” and becomes angry toward R1, which makes other residents uncomfortable. Resident 6 also confirmed hearing R2 yell at R1 frequently and stated that R1 often leaves the bedroom and goes to the living room because of the yelling.



(Continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20251125133020
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: SUNSET COAST ASSISTED LIVING
FACILITY NUMBER: 374604350
VISIT DATE: 03/18/2026
NARRATIVE
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(Continue from LIC9099C)

Interviews with outside sources also supported the allegation. A medical provider who visits the facility regularly to provide services reported witnessing R2 yelling at R1 and using offensive language toward R1 during visits. The outside source reported that R2 directs this behavior specifically toward R1 and not toward other residents. It was stated that staff typically intervene by separating the residents and that R1 often leaves the room to avoid confrontation. Although no physical aggression between the residents was observed during those visits, the outside source indicated concern that R1 must routinely tolerate verbal abuse in the living environment.

Similarly, another medical provider who has provided services at the facility reported witnessing R2 yelling aggressively toward R1 and occasionally toward staff. It was reported that during one incident, R2 became aggressive toward R1 and the provider requested that staff remove R1 from the room so that R2 would calm down.

In addition, an outside source reported overhearing R2’s verbal aggression toward R1 during telephone calls. It was reported that R2 yelled profanity and threats toward R1, including statements in Spanish instructing R1 to leave the room and threatening harm. During the interview, it was stated that the verbal aggression had been occurring for several months and had caused emotional distress for R1. Concern was also expressed after learning about the water bottle incident, as the behavior appeared to be escalating.

During facility observations conducted on December 3, 2025, LPA observed that R2 was eating separately from other residents because R2 did not want to sit near R1. During the visit, R1 was observed eating with other residents in the dining area while R2 ate alone in the living room. Interviews and observations confirmed that R1 frequently spends time in the living room rather than the shared bedroom due to R2’s behavior.

Although staff reported that they intervene when R2 becomes verbally aggressive and separate the residents to de-escalate the situation, the investigation found that R2’s verbal abuse toward R1 has been ongoing for approximately nine months and continues to occur despite staff intervention.
(Continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20251125133020
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: SUNSET COAST ASSISTED LIVING
FACILITY NUMBER: 374604350
VISIT DATE: 03/18/2026
NARRATIVE
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(Continue from LIC9099C)

The separation strategy often results in R1 being removed from the shared bedroom and common areas in order to avoid conflict, which limits R1’s ability to use personal living space.

Based on observations, record reviews, and interviews with staff, residents, and outside sources, there was sufficient evidence to support the allegation that staff did not protect R1 from verbal abuse. Verbal outbursts by R2 were reported. The evidence indicated that staff took actions to mitigate behaviors by separating the residents; however, the measures taken have not ensured that R1 is protected from abuse and infringe on personal rights to a safe living environment and personal space. The preponderance of evidence standard was met; therefore, the allegation is deemed Substantiated. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations, and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Licensee, Patricia Tapia.

An exit interview was conducted with Licensee Patricia Tapia via telephone. A copy of this report, LIC9000D, LIC811 Confidential Names, and the Licensee Appeal Rights (LIC 9058, 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20251125133020
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: SUNSET COAST ASSISTED LIVING
FACILITY NUMBER: 374604350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/20/2026
Section Cited
CCR
87468.1(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, humiliation, intimidation, abuse, or other actions … This requirement was not met as evidence by:
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Licensee agreed to submit a plan of corrections that clearly outlines and addresses how the facility will ensure residents are protected from verbal abuse and that residents’ personal rights are maintained. Licensee agreed to submit the incident report discussed on this report.
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Based on interviews, records review and observations it was determined the licensee did not protect R1 from verbal abuse by another resident (R2). This posed a potential health and safety risk for one (1) of six 6 residents in care.
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In addition, Licensee agreed to conduct additional in service training with all staff including Administrators and Licensee by an independent contractor on the regulation cited as it relates to personal rights.
Licensee agreed to submit documentation to CCL by POC Date of 4/20/2026
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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.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
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