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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603309
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:48:33 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
08/31/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230831085341
FACILITY NAME:BONITA RESIDENTIAL CAREFACILITY NUMBER:
374603309
ADMINISTRATOR:WA LAI BERNARTEFACILITY TYPE:
735
ADDRESS:4807 DEL PRADO STREETTELEPHONE:
(619) 942-3642
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY:6CENSUS: 6DATE:
09/07/2023
UNANNOUNCEDTIME BEGAN:
12:10 AM
MET WITH:Caregiver Theresa SyTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Medications were not given as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above allegation. LPA identified herself and discussed the purpose of the visit with Caregiver Theresa Sy. Administrator Wa Lai Bernarte arrived shortly after.

On August 31, 2023, Community Care Licensing (CCL) received information that staff did not issue Client 1 (C1) medication as prescribed.

During investigation, LPA Strong collected pertinent client records and conducted interviews as well as a facility inspection. Based on Client 1 (C1) Physician’s Report dated July 19, 2023, C1 is unable to self-administer or store medication.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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 3
Control Number 08-AS-20230831085341
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: BONITA RESIDENTIAL CARE
FACILITY NUMBER: 374603309
VISIT DATE: 09/07/2023
NARRATIVE
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According to allegation, C1 had multiple medication bubble packs not distributed on the dates of July 8, 2023, July 9, 2023, and July 10, 2023. According to interview with Administrator C1 was picked up from work on date of incident and staff were unable to prepare medication for weekend away. Interview also revealed that administrator did not attempt to communicate with C1 to collect medication. Interview with outside source revealed that they were unaware C1 missed medication and it is usually packed by staff for outings. Outside source also revealed that C1 does not have additional medication outside of facility. Records reviewed corroborated that C1’s medication was not physically issued on the dates mentioned above.

Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegation. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Administrator Wa Lai Bernarte, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230831085341
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: BONITA RESIDENTIAL CARE
FACILITY NUMBER: 374603309
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited
CCR
80075(a)(5)(B)
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80075 Health Related Services (5)Clients shall be assisted as needed with self-administration of prescription(B)Once ordered by the physician the medication is given according to the physician's directions.
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Licensee has conducted medication management training for self and staff as of 7/26/2023.
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This requirement was not met as evidence by:
Based on interviews and records reviewed the licensee did not provide medication for clients in 1 of 6 persons in care ([C1]) which posed a potential Health risk to persons 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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3