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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604177
Report Date: 02/10/2023
Date Signed: 02/10/2023 09:12:39 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/07/2022 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220307163632
FACILITY NAME:ATRIA BONITAFACILITY NUMBER:
374604177
ADMINISTRATOR:JULIA LOPEZFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:0CENSUS: 0DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Facility closed - Mailed to address on fileTIME COMPLETED:
08:45 AM
ALLEGATION(S):
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Facility did not conduct fire drills in more than three months.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Miller made a determination of findings and concluded the complaint investigation regarding the above allegation. The facility closed on January 20, 2023 due to a change of ownership, and this report was mailed to the address on record of the former licensee in order to share the finding.
On March 7, 2022, it was alleged that facility did not conduct fire drills in more than three months. The Department’s investigation consisted of interviews and available facility records. Attempts by the Department to obtain documentation from the facility and Licensee of fire drills done in 2021 and 2022 were not successful. Interviews with staff that worked during that time indicated that fire drills were not conducted during 2022.
Due to the facility not able to produce proof of conducted fire drills, the allegation that facility did not conduct fire drills in more than three months is found to be SUBSTANTIATED. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D. A copy of this report and Licensee's Rights (LIC9058) were mailed to the previous licensee on record.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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 6
Control Number 08-AS-20220307163632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA BONITA
FACILITY NUMBER: 374604177
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
87705(k)(3)
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CARE OF PERSONS WITH DEMENTIA: (k) The...requirements must be met for the licensee to utilize delayed egress devices...: (3) Fire and earthquake drills shall be conducted at least once every three months on each shift ...This requirement is not met as evidenced by:
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Deficiency cleared due to facility closure on
January 20, 2023.
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Based on interviews and record reviews, the facility did not conduct fire drills in more than three months which posed a safety risk to residents 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.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/07/2022 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220307163632

FACILITY NAME:ATRIA BONITAFACILITY NUMBER:
374604177
ADMINISTRATOR:JULIA LOPEZFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:0CENSUS: 0DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Facility closed - Mailed to address on fileTIME COMPLETED:
08:45 AM
ALLEGATION(S):
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Staff did not supervise residents take medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Miller made a determination of findings and concluded the complaint investigation regarding the above allegation. The facility closed on January 20, 2023 due to a change of ownership, and this report was mailed to the address on record of the former licensee in order to share the finding.

On March 7, 2022, it was alleged that staff did not supervise residents take their medication. The Department’s investigation consisted of interviews and available facility records.

A random selection of Medication Administration Records (MAR) of various residents showed that medication were correctly logged and included the prescribing physician, the drug name, strength and quantity, the date filled, the prescription number, issuing pharmacy, and medication instructions. All records were initialed and a key for all initials was legible.
[Page 1 of 2, Continued on LIC9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20220307163632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ATRIA BONITA
FACILITY NUMBER: 374604177
VISIT DATE: 02/10/2023
NARRATIVE
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[Page 2 of 2, Continued from LIC9099]

An outside source interview witnessed Resident 1 (R1) leaving the facility and a medication technition (med tech) following them. When R1 asked why the med tech was following R1, med tech stated that they needed to ensure that R1 took their medication. Outside source witnessed med tech supervise R1 as they took their medication. R1 had never stated to the outside source that staff did not supervise them when they took their medication. R1 also stated that they had always been supervised while they took their medications and did not recall a time when they weren’t.

Several residents, who did not need assistance with medication management, witnessed staff supervising residents as they took their medication in the dining room. Staff interviews indicated that residents given medications by med techs were always supervised to ensure that medications were taken. Staff 1 (S1) and Staff 2 (S2) stated that they always supervised residents to ensure that their medication was ingested. They did not indicate that they knew of any staff who did not supervise residents while they ingested their medications.

Based on the evidence obtained during the complaint investigation, the allegation that staff did not supervise residents take medication is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report and Licensee's Rights (LIC9058) were mailed to the previous licensee on record.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/07/2022 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220307163632

FACILITY NAME:ATRIA BONITAFACILITY NUMBER:
374604177
ADMINISTRATOR:JULIA LOPEZFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:0CENSUS: 0DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Facility closed - Mailed to address on fileTIME COMPLETED:
08:45 AM
ALLEGATION(S):
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Facility did not provide residents with an updated contract.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Miller made a determination of findings and concluded the complaint investigation regarding the above allegation. The facility closed on January 20, 2023 due to a change of ownership, and this report was mailed to the address on record of the former licensee in order to share the finding.

On March 7, 2022, it was alleged that facility did not provide residents with an updated contract, specifically after a change in ownership. The Department’s investigation consisted of review of facility and internal records.

Facility records revealed a letter sent on November 11, 2022 from Carl Knepler, Senior Vice President of Pacifica Senior Living, to residents regarding the facility’s change of ownership. The letter stated that “a change of ownership and management will occur at Atria Bonita around December 16th, 2021.” An interview with Knepler was attempted but not successful.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20220307163632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ATRIA BONITA
FACILITY NUMBER: 374604177
VISIT DATE: 02/10/2023
NARRATIVE
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The Department issued an updated license on July 6, 2022 to reflect that the facility’s name changed from Atria Bonita to Pacifica Senior Living Bonita and that Pacifica Senior Living Management LLC was being added to the license. The new license did not grant a new license number, meaning that the original Licensee had not been removed.

The Department received an application for a change of ownership on January 12, 2022. After submitting all necessary fees and documentation, the Department granted a new license and license number on January 20, 2023 to Pacifica Ca LLC, Bonita LP, and Pacifica Mgmt LLC. The facility became known as Pacifica Senior Living Bonita, 374604544.

Based on the evidence obtained during the complaint investigation, the allegation that facility did not provide residents with an updated contract is found to be UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. A copy of this report and Licensee's Rights (LIC9058) were mailed to the previous licensee on record.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6