Sun City Gardens.

Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Executive Director Patricia Russell ,informed her of the purpose of the visit and was granted access. Community Care Licensing (CCL) received a SOC 341 from the facility indicating an alleged physical abuse by Staff 1(S1) toward resident 1 (R1). LPA's case management included interview with staff , obtaining pertinent documentation and conducting a tour of the facility for a health and safety check. No immediate health and safety concerns were observed during today's visit. Executive Director Patricia Russell informed LPA that an internal investigation was conducted and S1 was terminated. Executive Director Patricia was advised that possible visits and phone interviews will be conducted before a decision is rendered. An exit interview was conducted and a copy of this report was provided to Executive

On 02/11/2026, Licensing Program Analysts (LPAs) Jacqueline Shaw Ross and Venus Mixon, made an unannounced visit to the facility to conduct an annual review. LPAs were greeted by facility staff and granted entry. Executive Director Patricia Russell arrived shortly, and the purpose of the visit was explained. A tour of the facility was conducted inside and out. Resident record review began- A total of six (6) client records were reviewed that included admission agreements, medical assessments and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPAs toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature was logged and tested within regulations. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in a closet. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPAs verified there is a telephone working at this location. Food Service- Food supply was observed and meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. Review of Employee Records- LPAs reviewed employee records that included employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification. CPR and requirements have been met. Cont'd on LIC 809C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The facility employs an appropriate number of staff to maintain cleanliness and meet the needs of the clients in care. The Administrator's certification is current. LPAs made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested annually and were replaced on 02/05/2026. The facility is conducting emergency disaster drills and met regulations and was logged. The last disaster drill was conducted on 02/05/2026. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted and a copy of this report was provided to Executive Director, Patricia Russell.

(continued from LIC 9099) Regarding the allegation that Staff did not ensure resident’s room was adequately cleaned, it was alleged that R1's room had urine multiple urine stains. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that they regularly do a light cleaning on everyone's room and the housekeeper do general cleaning of everyone's room once a week. LPA's interview with housekeeping staff yesterday 05/17/25, revealed that they shampoo R1's room whenever requested by the former Resident Service Director (RSD) but denied that it had urine stains. LPA's interview with six (6) Assisted Living (AL) residents revealed six (6) out of six (6) residents state that their room are being cleaned regularly by staff and do general cleaning once a week. Regarding the allegation that Staff did not assist resident with personal hygiene care, it was alleged that staff did not make sure that R1's hands were clean and did not file R1's nails and staff also did not wash R1's face or help brush R1's teeth. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that during their shift (AM) they regularly assist R1 getting up to bed, clean, brush teeth, shower during schedule days and dress and groom before breakfast every day. They stated however that cutting and filing nails were not part of their duty as it may hurt R1 so they had to bring R1 to a podiatrist or a salon. Further, when R1 was admitted to Hospice care, the hospice staff were doing R1's bathing and grooming, including but not limited to nail trimming and filing, shaving, etc., LPA’s record review of hospice notes confirmed that the hospice staff were assisting on R1's ADLs. Regarding the allegation that Staff did not dispense resident’s medication as prescribed, it was alleged that R1 was being over medicated because staff were dispensing medications as directed by an old doctor’s order and not the newest order. LPA's record review revealed that since R1 started on Hospice services, it was the hospice staff checking and reconciling R1's medication and due to R1's condition medication orders changed faster than usual. Further review revealed that all the medications administered to R1 from the period August 2024 up to the time of R1's passing on October 2024 were given as prescribed. (continued on LIC 9099-C-2) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (continued from LIC 9099-C) Regarding the allegation that Staff did not refill resident's medication in a timely manner, it was alleged that R1 ran out of heart medication but staff did not inform RP until one week later. LPA's record review revealed that R1 was using facility non-contracted pharmacy, in which the family member and/or responsible party are the ones responsible for contacting the pharmacy for refills. Further review also revealed that R1 did not miss any regularly prescribed medication from July 2024 until the time of R1's passing on October 2024. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

(continued from LIC 9099) LPA Goodrich's interview with former Resident Care Director (RSD) on 08/22/23 and Executive Director on 09/11/23 revealed that they have contacted and worked with APS and other agency to have R1 appointed a Public Guardian but nothing happened. The facility contacted and located R1's family member and eventually had a family member as a responsible party for medical and financial matters for R1 on 01/18/2024. During this visit, LPA observed that R1 now resides at the facility's memory care unit and observed to be neat, clean and stated that staff are taking good care of R1. Further review also revealed that on 05/21/24, R1 was appointed a temporary public guardian from Riverside County Public Guardian office by the Superior Court of California, County of Riverside Based on the information gathered during this and prior visit, there is insufficient evidence to prove the allegation and therefore deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

The LPA reviewed hospice notes dated from September 29, 2023, to February 27, 2024, and found that hospice nurses consistently educated caregivers and medical technicians during each visit to the facility. The topics covered included repositioning techniques, aspiration precautions, and R1's feeding position. LPA interviewed two (2) hospice nurses who observed R1’s bruises. Both nurses confirmed the bruises were likely from someone’s hand, but neither nurse was able to tell what or who caused the bruises. Both nurses asked the facility caregivers about R1’s bruises at the time of the discovery, but none of the caregivers had any knowledge of events or incidents that could explain R1’s bruises. Based on LPA’s record reviews and staff interviews, the investigation did not reveal corroborating evidence to determine the cause or source of R1’s bruises. Therefore, the allegation is determined to be Unsubstantiated . A finding of Unsubstantiated indicates that while the allegation may have occurred or been valid, there is not a preponderance of evidence to conclusively prove that the alleged violation took place. An exit interview was conducted where a copy of this report was provided.

On December 10, 2023, R1 was sent to the hospital due to an urgent health condition and did not return to the facility afterward. According to records, R1 remained at a skilled nursing facility until March 15, 2024. A Resident Move Out form dated April 24, 2024, confirmed R1 never returned to Sun City Gardens and officially moved out on May 2, 2024. Interviews with two staff members who provided care to R1 revealed R1 was non-ambulatory and R1 was able to stand up and walk. In addition, a Pre-placement appraisal dated June 7, 2023, indicated R1 required use of a walker and or wheelchair. Staff frequently reminded R1 to use a wheelchair due to R1’s tendency to move around without it, but neither staff member recalled R1 having pressure injuries during their time at the facility. Information obtained during this investigation did not corroborate the alleged allegation of R1 sustaining pressure injuries while in care. Based on record reviews and staff interviews, this allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.

(Continued from Page 1) It was not advised if Resident #1 notified staff that a replacement was needed. LPA attempted to interview R#1, but due to R1’s cognitive ability, LPA was unable to verify resident was a reliable historian of record. During a visit to the facility, LPA observed a bedside lamp that was unplugged. The lamp was plugged in and had a working light bulb. LPA checked the other light sources, and they were all in working condition. LPA conducted a review of service requests and there were no requests to replace a light bulb in the resident’s room. Documentation did state that Resident #1 will often unplug their personal lamp and housekeeping will plug the lamp back in. Based on interviews and facility records, the allegation that staff did not replace a light bulb in a resident’s room is Unsubstantiated. Although the allegation may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Joey Collado, ED and a copy of this report along with LIC811- Confidential Names list was provided.

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility with LPA identification and business card. Resident record review began- Six (6) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 112.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in a closet. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA began review of employee records- Seven (7) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification. CPR and requirements have been met. (Continued on next page) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from Page 1) The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification has been renewed, expired in November 2024 and is pending in the database. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 03/24/2024. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 12/15/2024. Resident bedrooms flooring, bathrooms and common areas are being renovated; there was construction observed. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative at the time of the exit interview. *LPA was away from the facility from 12:15-1:15 PM.

(Continued from Page 1) During the LPA’s interview with Executive Director and Business Office Director, it was concluded that R#1 has never been a resident in the Assisted Living and Memory Care, R#1 is an Independent Living resident. Based on LPA's observations, records review, and staff interview, this agency has investigated the complaint alleging “wrongful eviction” and "staff are retaliating against resident for complaining" we have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to facility representative.

someone up front but if assistance was needed a call would need to be made and the 24/7 staff inside the back building would assist. LPA conducted a records review of the rent roll and facility census, that revealed R1 resides in the independent building. The department does not have jurisdiction over the independent living units of the facility. Therefore the allegation of facility staff did not provide adequate supervision to resident in care is UNFOUNDED at this time. A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. A exit interview was conducted and a copy of this report along with LIC811 - confidential names list was provided to Diane Domingo, Administrator.

receiving additional services from a third party agency. Per the narrative charting dated 7/7/24 reviewed revealed that R1 was admitted to the facility with the wounds, therefore the allegation of due to neglect, resident sustained pressure injuries/bruises is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to Executive Director Elizabeth "Diane" Domingo.

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On February 07, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced in order to conduct the required annual inspection. LPA Mixson met with Bituin Garcia, introduced self, and stated the purpose of the visit. The File review was conducted in the office and additional forms were requested and reviewed on site. LPA Mixson toured the facility, along with the Administrator, Bituin Garcia, and inspected the inside and outside of the facility. The facility is a two story building located at 28500 Bradley Road, Sun City CA. 92586. The Facility is licensed for 74 Elderly Adults and is operating at a capacity of 69. The facility phone number is (951)679-2391 and it is operable. Physical Plant: The physical plant, is in good condition, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of this visit. The Facility has several activity rooms and each has the required furniture; such as tables, chairs, storage space, and sufficient lighting. The building temperatures throughout was per regulations. The activity rooms are equipped with the required items, per Title 22. The hot water temperature was tested in several of the restrooms, in which they each tested within the range required for regulations. The restrooms were equipped with liquid soap and paper towels. LPA Mixson toured the kitchen and staff were preparing evening meal. The facility had activity schedules posted and available for review. The Facility has emergency food and water. LPA Mixson inspected the common areas. The fire extinguisher was in the green and the Facility recently had fire inspection. Carbon monoxide alarms, along with smoke detectors were observed. There was a locked and centralized storage area for medications in the nurses station and it was locked. Medications are contained in bubble packs, and supplied by the Pharmacy. The Facility had a designated area for resident and staff files, and it was locked. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and sufficient space for activities. LPA Mixson observed monthly activity calendars, a swimming pool gated and locked. LPA Mixson reviewed staff and resident files, and conducted five staff interviews and resident interviews. There were no regulation violations observed during todays visit. An exit interview was conducted and a copy of this report was provided to Bituin Garcia.