SUNGARDEN TERRACE

Official classification

Type B

Official code

87469(c)(3)

Regulation authority

CCR

What the official deficiency says

87469 Advanced Directives and Requests Regarding Resuscitative Measures: “(c)(3) Specifically for a terminally ill resident that is receiving hospice services…For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” This requirement was not met, as evidenced by: Based on records and interviews, when 1 of 45 residents (R1), who was receiving hospice services, experienced a medical emergency not directly related to the expected course of their terminal illness, Licensee did not immediately telephone emergency response (9-1-1) for them. This posed a potential health risk to persons in care.

Official plan of correction

Licensee agreed to conduct in-service retraining for current staff on Licensee’s existing “Medical Emergency” written policy and regulations CCR 87465 and 87469. (The texts of these regulations were provided to the administrator during today’s visit.) Licensee agreed to E-mail a copy of the training sign-in to LPA, by the POC due date.

Deadline recorded: May 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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…(D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by: Based on records and interviews, 1 of 45 residents (R1) experienced an incident which threatened their welfare and/or health, and Licensee did not submit a written report to the licensing agency and the resident’s responsible person within seven days. This posed a potential personal rights risk to persons in care.

Official plan of correction

During today’s visit, LPA provided the facility administrator training on LIC624 Incident Reports and the full text of CCR 87211. Licensee agreed to write an LIC624 Incident Report describing their current knowledge regarding R1’s fall on 03/31/2026, and to E-mail a copy of this to both R1’s RP and CCLD (CCLASCPSanDiegoRO@dss.ca.gov), bcc’ing LPA on both E-mails, by the POC due date.

Deadline recorded: Apr 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69(g)

Regulation authority

HSC

What the official deficiency says

(g) Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility’s medication management program and procedures at least twice a year. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and manager interview, Licensee's facility is licensed for more than 16 residents, but Licensee did not maintain documentation that a consultant pharmacist or nurse had reviewed the facility's medication management program and procedures at least twice per year. This posed a potential health risk to 49 of 49 residents (R1 through Resident #49) in care.

Official plan of correction

POC Due Date: 04/27/2026 Plan of Correction Licensee agreed to either hire a Resident Services Director who is a currently a licensed nurse in California, or to retain the services of a consultant pharmacist or nurse to review the facility's medication management program and procedures at least twice per year. Licensee agreed to E-mail proof that either a nurse has been hired to join the facility's team, or that an outside consultant pharmacist/nurse has been performed the review, by the POC due date.

Official classification

Type B

Official code

87506(b)(9)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and manager interview: For 4 of 5 sampled residents (R2 through R5), Licensee did not have in their record of care the name, address, and telephone number of a dentist to be called in an emergency. For 1 of 5 sampled residents (R2), Licensee did not have in their record of care the name, address, and telephone number of a physician to be called in an emergency.This posed a potential health risk to persons in care.

Official plan of correction

POC Due Date: 04/27/2026 Plan of Correction Licensee agreed to communicate with necessary parties to update the Facesheets for R2 through R5. If a resident does not have a preferred physician and/or dentist, Licensee may list a default mobile professional who can be called for emergencies, until a preferred one is provided. Licensee agreed to E-mail the updated Facesheets for R2 through R5 to LPA, by the POC due date. Licensee agreed to self-audit remaining Facesheets for physician and dentist information.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, Licensee did not ensure that the pre-admission medical assessment for 1 of 5 sampled residents (R1) included the test results of an examination for communicable tuberculosis. This posted a potential health risk to persons in care.

Official plan of correction

POC Due Date: 04/27/2026 Plan of Correction Licensee agreed to coordinate with R1’s current physician and/or hospice agency to have a PPD skin test or chest x-ray performed on R1. Licensee agreed to E-mail the negative tuberculosis (TB) test result to LPA, by the POC due date. Licensee agreed to self-audit all remaining client records to ensure complete TB records are on file.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

1569.695 Emergency Plans: “(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following…” This requirement was not met, as evidenced by: Deficient Practice Statement Based on records review and manager interview, Licensee did not have an emergency and disaster plan for hte facility that met regulatory requirements. This posed a potential safety risk to 49 of 49 residents (R1 through Resident #49) in care.

Official plan of correction

POC Due Date: 04/27/2026 Plan of Correction Licensee agreed to complete all pages of form LIC610E (version 3/19), and E-mail a copy of it to LPA, by the POC due date. Going forward, Licensee agreed to train all staff on this document, both at time of hire and at least annually thereafter.

Official classification

Type B

Official code

87467(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and manager interview, for 5 of 5 residents (R1 through R5), Licensee did not within the last 12 months arrange a meeting with the resident and required individuals to review and revise the resident's written record of care. This posed a potential health risk to persons in care.

Official plan of correction

POC Due Date: 04/27/2026 Plan of Correction For R1 through R5 each, Licensee agreed to conduct a care conference with their responsible person (and visiting care agency personnel, as applicable) to review the resident's facility Plan of Care, updating it as needed. All parties to the meeting will sign. Licensee agreed to E-mail proof of care conference completion to LPA, by the POC due date. Going forward, Licensee agreed to facilitate such care conferences at least once every 12 months for each resident.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met, as evidenced by: Interviews and records review for 1 of 44 residents This poses an immediate health risk to residents in care.

Official plan of correction

LPA and facility administration jointly agreed to have all staff in serviced regarding Resident Rights by 9/8/25

Deadline recorded: Sep 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87413(a)(3)

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights: The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation or prejudice. This requirement was not met, as evidenced by interviews and records review for 1 of 44 residents. This poses an immediate health risk to residents in care.

Official plan of correction

LPA and facility administration jointly agreed to have all staff in serviced regarding Personnel Reporting requirements by 9/8/25

Deadline recorded: Sep 8, 2025. A deadline is not proof that correction was completed.