306005423-5-12-2026-22-AS-KSGH-DUYVKE-20260612163012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005423
Report Date: 05/12/2026
Date Signed: 05/12/2026 10:32:55 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230120113000

FACILITY NAME:	SUNRISE ASSISTED LIVING AT TUSTIN		FACILITY NUMBER:	306005423
ADMINISTRATOR:	BRYAN REAMER-YU		FACILITY TYPE:	740
ADDRESS:	12291 S NEWPORT AVE		TELEPHONE:	(714) 544-5959
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	0	CENSUS: 52	DATE:	05/12/2026
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Sandra Acosta-Louer		TIME COMPLETED:	09:59 AM

ALLEGATION(S):

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Resident sustained pressure injuries due to staff neglect
Staff did not prevent resident from falling out of bed
Staff left resident in soiled diaper for extended period of time
Staff did not safeguard resident personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the allegation listed above. LPA was greeted and granted entry by staff after an introduction and stating the purpose of the visit.

The complaint investigation was initiated by LPA Jerome Haley on January 26, 2023, regarding complaint allegations filed on January 20, 2023. The complaint was investigated by the Department and consisted of the following: a tour of the physical plant, document review, and interviews with facility staff including the Executive Director Bryan Reamer-YU, Health Services Director, and a licensed nurse.
During the investigation 8 of 8 facility staff members were interviewed during the investigation and all 8 staff members provided information that directly contradicts the complaint allegation. During interviews it was discovered, R1 has diagnoses of edema, hypertension, high blood pressure,

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

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 5

Control Number 22-AS-20230120113000

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNRISE ASSISTED LIVING AT TUSTIN	FACILITY NUMBER: 306005423
	VISIT DATE: 05/12/2026

NARRATIVE

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R1 suffers from dry skin, and R1 is incontinent, which contribute to R1's history of pressure ulcers that started before their arrival at Sunrise Assisted Living At Tustin.

During interviews with multiple staff members, it was confirmed that R1 had a history of pressure ulcers and the staff were instructed to take preventative measures to prevent skin breakdown. Based on a statement obtained from the facility’s Health Services Director (HSD), facility staff made sure to oil between R1’s legs, wear foam booties to relieve pressure on the feet/ankle and even suggested a special diet for R1 since the resident was incontinent which contributed to skin breakdown. According to a facility staff person, facility staff implemented all the preventative measures from R1’s care plan in order to keep R1’s wounds from progressing, including moving the resident every two hours and multiple diaper changes throughout the day.

Documents reviewed confirmed the measures in place to manage R1’s pressure ulcer. According to R1’s service plan, on January 7, 2023, it was documented that a Hospice nurse would be providing treatment for R1 reopened wound on the L heel. Further, it was documented that the facility would provide/ensure the use of pressure relieving devices including pillows, foam booties for R1’s bed and chair, and would monitor R1’s dressings to ensure they remain intact, and loose, soiled, or absent dressings would be reported to the hospice nurse.

According to a timeline breakdown provided by a family member of R1, on January 13, 2023, R1 was removed from hospice due to R1 being sick and facility staff sending R1 to the hospital at a family members request.

An incident report sent to the Orange County Adult and Senior Care Regional Office dated January 13, 2023, confirmed the details provided in the timeline breakdown.

Regarding the allegation: Staff did not prevent resident from falling out of bed.

During the investigation 8 of 8 individuals failed to provide any corroborating information or evidence to support the allegation and all the information provided contradicted the complaint allegation. Document review also failed to provide any corroborating information.

Continued on LIC9099C pg 2 of 5

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 22-AS-20230120113000

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNRISE ASSISTED LIVING AT TUSTIN	FACILITY NUMBER: 306005423
	VISIT DATE: 05/12/2026

NARRATIVE

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According to Executive Director Reamer-YU, R1 was a fall risk, and the facility had measures in place like fall mats, low air mattresses, and easy to reach call switches. According to Executive Director Reamer-YU, R1 didn’t have issues with falling, as their hospitalization's were related to pressure injuries. According to Former Staff (FS8), R1 was a fall risk; however, FS8 did not remember R1 having any falls. FS8 confirmed the facility implemented measures like low air mattresses, floor mats, call buttons within reach, and staff placed pillows near R1 when the resident slept to prevent R1 from falling or rolling off the bed

Additionally, an interview with R1’s responsible person confirmed they were notified by the facility after falls occurred. Statements gathered during interviews indicated R1’s family purchased two cushions for R1 to use in case the resident fall out of bed and rented R1 a lower bed June 1, 2022. According to family statements, there were no more falls after the lowered bed was rented.

Regarding the allegation: Staff left resident in a soiled diaper for extended period of time

During the investigation 1 of 8 individuals were able to provide information that supports the complaint allegation. All other staff members interviewed claim residents are changed every two hours or as needed.

Staff 4 (S4), claim staff on the night shift document residents are being changed every two hours, but the residents are not actually changed. S4 accused a former staff member who was employed temporarily to care for R1. S4 claims they went to their manager, Staff 5 (S5) to address the concerns and after S4 spoke with S5, things got better.

FS8 is a former facility staff person who’s worked at Sunrise for two years and is familiar with R1. FS8 claims R1 was severely incontinent, and facility staff had to change R1 every two hours, and staff checked on R1 constantly. S5 claims R1 was always wet when it was time to change the resident and sometimes R1 needed to be changed before two hours had passed. According to S5, R1 was capable of informing staff they (R1) needed to be changed or go to the restroom.

S5 denied the allegation and stated residents are changed every two hours. S5 explained if they hear any complaints or concerns that a resident was not changed, S5 will review who’s responsible for the residents’ care and check to see what time the resident is being changed. S5 explained, if it’s discovered that a resident has not been changed the staff member will receive a verbal warning; if it continues, facility staff will move to written documentation, which can lead to time off, and if it continues it can result in termination. According to S5, they have never had to write up a staff member for not changing a resident’s diaper.

Continued on LIC9099C pg 3 of 5

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20230120113000

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNRISE ASSISTED LIVING AT TUSTIN	FACILITY NUMBER: 306005423
	VISIT DATE: 05/12/2026

NARRATIVE

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Regarding the allegation: Staff did not safeguard resident personal belongings

During the investigation 8 of 8 individuals failed to provide any corroborating information or evidence to support the allegation. According to multiple staff members who were interviewed, including the Executive Director Reamer-YU, laundry is done individually and residents use a laundry bag or basket when their clothes are washed. S1 said the facility does not mass wash clothing. S4 says laundry is done at night, washed, folded, and put back in the resident’s room. S4 says when the laundry is being washed, you put the clothes in the wash, put the name and room number back on the board, wash, fold, then put back in the resident’s room. S4 added that they have been working at the facility for five years so if someone’s items are mixed up, S4 will have a good idea who they belong to, and staff will go door-to-door if they need to.

During the interview with staff, many of them were unaware if residents are required to fill out a personal item inventory or not. According to Executive Director Reamer-YU resident families are provided with the personal item inventory, but a lot of them choose not to complete it. S5 was asked if residents are required to fill out a personal item inventory for residents and the staff member said they believe so. S5 added that the sales/marketing team handles that part of the process and S5 is still new and has not received that training yet but should receive it soon.

A statement gathered during the investigation alleged that several pairs of R1’s shorts/pants came up missing and had to be replaced; however, no details such as dates or specific information about the missing items or the dates of the alleged losses were provided during the investigation. Additionally, R1’s responsible party declined to fill in an inventory of valuables upon admission.

Regarding the allegation: Staff did not make sure resident was fed

During the investigation 8 of 8 individuals failed to provide any corroborating information or evidence to support the allegation.

Witness interviews conducted during the investigation failed to disclose more detailed information about the allegation under review. It was alleged that one evening when R1 returned to Sunrise Assisted Living at Tustin from a skilled nursing facility (SNF), it was evening time and the PM shift failed to provide R1 with a meal and R1 was left in their wheelchair all night after staff failed to attend to the resident.

Continued on LIC9099C pg 4 of 5

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20230120113000

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNRISE ASSISTED LIVING AT TUSTIN	FACILITY NUMBER: 306005423
	VISIT DATE: 05/12/2026

NARRATIVE

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It was alleged that a facility staff person called R1’s responsible person the next day to notify them that the alleged incident occurred. However, during the investigation no one could remember what facility staff member made the call to R1’s responsible person.

During interviews with facility staff, none of them could recall such an incident taking place. According to Executive Director Reamer-YU, if a resident is admitted after normal business hours, there are plenty of ways a resident will be fed. Executive Director Reamer-YU added, food/snacks are left out that residents have access to.

Regarding the allegation: Staff are falsifying resident documents

During the investigation 1 of 8 individuals interviewed provided information that supports the complaint allegation. S4 claims some of the staff who work on the night shift will document residents are being changed every two hours; however, the night staff are not really making the changes because residents are found wet. S4 claims a former staff member who worked for about three weeks was responsible for doing this. However, S4 said they spoke to their supervisor regarding their concerns about residents being left wet, and after their conversation the situation improved.

According to FS8, R1 always needed to be changed. FS8 said R1 would let staff know when they needed to be changed and sometimes R1 needed changing before the two hours they were required to check on the resident passed. FS8 stated that a family member of R1 never had any concerns about R1’s care at the facility.

During the investigation, while interviews were being conducted by the department, one individual relayed an indirect statement allegedly made by a staff member indication incontinent care logs were forged and the care being documented was not actually provided. However, there was no corroborating information or evidence provided that supports the statement about incontinent care logs being forged by staff.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed unsubstantiated.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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