374604177-3-22-2023-08-AS-SJAB-CQ7VQG-20230323163815

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604177
Report Date: 03/22/2023
Date Signed: 03/22/2023 09:58:40 AM

Unsubstantiated

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
01/19/2023 and conducted by Evaluator Elizabeth Hamilton

COMPLAINT CONTROL NUMBER: 08-AS-20230119081108

FACILITY NAME:	PACIFICA SENIOR LIVING BONITA		FACILITY NUMBER:	374604177
ADMINISTRATOR:	LEON II, RENE		FACILITY TYPE:	740
ADDRESS:	3434 BONITA ROAD		TELEPHONE:	(619) 476-9444
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	0	CENSUS: 0	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Report mailed to Licensee		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect resulting in resident injuries

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Elizabeth Hamilton sent this report to the former licensee's last known mailing address via USPS certified mail to deliver the investigation findings for the above allegation. This facility ceased operations on January 27, 2023.

The Department’s investigation consisted of record reviews, and interviews with staff and outside sources.

On January 19, 2023, it was alleged that staff neglect resulted in resident 1 (R1) sustaining injuries. It was alleged that on January 15, 2023, at approximately between 12:15 pm and 1:15 pm, R1 called for help through their pendent alarm after a fall, and no staff came to assist. Interviews revealed that on January 15, 2023, R1 was sent out to the hospital at approximately 6:00 am after R1 requested assistance through their pendant at 4:58 am for an unrelated medical need. R1 returned to the facility from the hospital with outside source 1 (OS1) around 11:00 am.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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 2

Control Number 08-AS-20230119081108

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: PACIFICA SENIOR LIVING BONITA	FACILITY NUMBER: 374604177
	VISIT DATE: 03/22/2023

NARRATIVE

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

After OS1 left R1 at the facility, approximately one hour later, outside source 2 (OS2) arrived to R1’s apartment and found them in their bed, bleeding from the back of the head from a fall. Records reviewed revealed R1 was an independent resident; however, had an alarm pendant. Records further revealed that during the time in question, R1 did not utilize their alarm system; however, records corroborated R1 only requested assistance by alarm on the day in question at 4:58 am.

The Department has investigated the allegation listed above. Based on evidence obtained, including interviews and records reviewed, the above allegation is determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard.

A copy of this report, and appeals rights (LIC 9058 1/16) were sent to the licensee's last known address on record via USPS certified mail due to facility closure.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2