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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604177
Report Date: 04/14/2025
Date Signed: 04/14/2025 06:25:23 PM

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
07/11/2022 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20220711144305
FACILITY NAME:PACIFICA SENIOR LIVING BONITAFACILITY NUMBER:
374604177
ADMINISTRATOR:MARKOVICH, PAULFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:0CENSUS: 0DATE:
04/14/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:N/A. Report Certified Mailed to Licensee.TIME COMPLETED:
07:00 PM
ALLEGATION(S):
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-Licensee did not employ staff in numbers necessary to meet resident need(s).
-Staff did not provide needed observation to resident(s).
-Staff did not provide needed bathing assistance to resident(s).
-Licensee did not provide residents the required variety of planned activities.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior complaint allegations. Since the facility ceased operations on 01/19/2023 due to Change in Ownership, these allegation findings were delivered to the Licensee via USPS certified mail.

The Complainant alleged that Licensee did not employ staff in numbers necessary to meet resident needs, that staff did not provide needed observation to Resident #1 (R1), that staff did not provide needed bathing assistance to residents, and that Licensee did not provide residents the required variety of planned activities. [See LIC 811 Confidential Names List for a description of R1.] CCLD’s investigation involved an unannounced facility tour/welfare check and review of pertinent facility care records and outside agency reports. The Department also interviewed four (4) facility managers, eight (8) frontline staff, ten (10) residents, and one (1) outside source, each of whom was relevant to the facility during the complaint allegation timeframe.

[CONTINUED ON LIC 9099-C, 1 of 5]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
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 11
Control Number 08-AS-20220711144305
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: 04/14/2025
NARRATIVE
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[CONTINUED FROM LIC 9099]

Regarding the staffing allegation, the Complainant said throughout the first half of 2022, there was shortage of facility staff at caregivers, med techs, and dining room server positions on the AM and PM shifts. CCLD interviewed the then-facility administrator, Staff #1 (S1). S1 said during the first half of 2022, the facility had around “a dozen” frontline staff leave employment, of which close to “80%” were Licensee-initiated terminations. By the time CCLD received the complaint and began investigating in July 2022, S1 admitted the facility was still understaffed in caregivers despite recruitment efforts. S1 admitted to not attempting to use third-party Home Care Organizations (HCOs) to supplement caregiver staffing, despite being aware of how to hire them. Interviews of other managers, frontline staff, residents, and an outside source widely corroborated that the facility had a chronic shortage of caregivers during the allegation timeframe. Interviews were mixed on whether there were med tech and dining room server shortages. A few persons indicated managers sometimes work alongside frontline staff to supplement them on the floor, but some said these were for short bursts (and not full shifts).

In their interview, S1 explained that Licensee employed a variable staffing model, where the facility’s labor budgets for caregiver and med tech were determined/adjusted biweekly based on total resident census and care acuity (as determined by residents’ assessed care and medication assistance levels; each level corresponded to a different customer price paid and to a different allotment of labor hours). Licensee’s target for dining room servers was four (4) staff per day. CCLD studied the facility’s May and June 2022 financial statements, as they related to staffing in the Resident Care (includes caregiver), Skilled Care (includes med tech), and Dietary (includes dining room server) departments. The financial data showed during this review period: Resident Care actual labor ran far below budgeted/target labor; the facility used only 58.17% of the budget/target for this line item, even after accounting for overtime. Also, Dietary labor variance was statistically significant; the facility used only 87.26% of the budget/target for this line item, even after accounting for overtime.

[CONTINUED ON LIC 9099-C, 2 of 5]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 11
Control Number 08-AS-20220711144305
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: 04/14/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 5]

In their interview, S1 said that based on resident census and assessed acuity levels, the facility was supposed to run with: Four (4) caregivers and two (2) med techs during AM shift (assisted living and memory care sections combined), and three (3) caregivers and two (2) med techs curing the PM shift (assisted living and memory care sections combined). CCLD studied caregiver and med tech work schedules from June 2022, comparing it to S1’s stated staffing targets, finding: Licensee missed the stated caregiver staffing target for AM shift on 73.3% of days. On these short days, 31.8% were missing two (2) caregivers (i.e., operating at half manpower), and 68.2% were missing one (1) caregiver (i.e., operating at three-quarters the required manpower). Licensee missed the stated med tech staffing target for AM shift on 23.3% of days. On these short days, 14.3% were missing two (2) med techs (i.e., operating at no coverage/manpower), and 85.7% were missing one (1) med tech (i.e. operating at half the required manpower). Licensee missed the stated caregiver staffing target for PM shift on 20% of days. On these short days, 16.7% were missing two (2) caregivers (i.e., operating at half manpower), and 83.3% were missing one (1) caregiver (i.e., operating at three-quarters manpower). Licensee missed the stated med tech staffing target for PM shift on 70% of days. On these short days, 9.5% were missing two (2) med techs (i.e., operating at no coverage/manpower), and 90.5% were missing one (1) med tech (i.e. operating at half the required manpower).

Several residents complained of long caregiver response times to their pendant devices. (Each resident was issued a call button which they wore on a necklace. When pushed, the button would send an electronic signal to caregivers’ pagers. Signals and response times were tracked in a central computer.) Per another manager’s interview, Licensee expected staff to respond to pedant calls within ten (10) minutes, but in practice staff were averaging “fifteen to twenty-five minutes” response time. CCLD extracted and studied a 72-hour window of electronic signals data, finding during the sampled period: There were a total of 170 pendant calls for service. Staff responded to nearly six out of ten calls (i.e., 59.41%) on time / within ten minutes. However, 13.53% of the calls were responded to between eleven and fifteen minutes, 15.29% were responded to within sixteen to twenty-five minutes, and 11.76% were responded to beyond twenty-five minutes.

[CONTINUED ON LIC 9099-C, 3 of 5]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 11
Control Number 08-AS-20220711144305
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: 04/14/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 5]

Regarding the observation allegation, the Complainant said during May 2022, R1 passed away inside their apartment at the facility and it took a few days for facility staff to learn that they were dead. Per the LIC624A Death Report which Licensee self-submitted to the CCLD San Diego Regional Office (RO): Around midday on 05/17/2022, a facility caregiver, Staff #2 (S2), heard R1’s pet cat crying, which prompted them to enter R1’s apartment to perform a welfare check. S2 subsequently found R1 lying in bed, “unresponsive,” “cyanotic” (means bluish or purplish skin), “cooled to the touch,” and with no vital signs, at which point 911 was called. According to San Diego County Sherriff’s Department (SDSO) records: On 05/17/2022, they received the report of R1’s death and visited the facility to investigate. The SDSO confirmed S2 was one who found R1 deceased. S2 told SDSO they walked by R1’s room and “noticed a bad smell,” which prompted S2 to enter, whereupon they saw “obvious signs of death.” The investigating deputy corroborated that “the odor of the deceased body and the cat litter was very strong,” and noted “lividity on the side of [R1’s] face in contact with [their] pillow and hand.” (Lividity, also known as livor mortis, is a postmortem phenomenon where the blood settles in the dependent parts of the body due to gravity after circulation ceases.) A Bonita Fire Department paramedic formally pronounced R1’s death. The San Diego County Medical Examiner’s (ME) declined to autopsy due to R1’s death appearing to be from natural causes (i.e., no foul play suspected). The official death certificate for C1, obtained from the San Diego County Office of Vital Records, showed C1’s final cause of death was “Cardiopulmonary Arrest,” secondary to their “Atrial Fibrillation, Atherosclerotic Heart Disease, and Hypertension.”

Care records, SDSO records, and interviews of staff aligned to show that from time of move-in, Licensee had assessed R1 as independent in activities of daily living (ADLs) and medication storage/administration. Staff thus did not check on R1 as often as their peers who did require care/medication assistance. However, R1 had lived at the facility a little over a month before they died and was known to eat many of their meals in the facility’s dining room. Per interviews of staff and other residents, R1 was last seen alive by staff around lunchtime on 05/13/2022, in the facility’s dining room. R1 did not attend meals or activities, nor was seen in any common area, over the next four (4) days. Staff did not find this odd enough to go check on R1. S2 told CCLD the smell of R1’s corpse permeated the entire second floor of the facility (where R1’s apartment was located), which prompted them to walk around and trace the smell to R1’s apartment door. [CONTINUED ON LIC 9099-C, 4 of 5]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 11
Control Number 08-AS-20220711144305
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: 04/14/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 4 of 5]

Multiple facility managers told LPA that while the date/time of R1’s biological death was unknown, there were concerns about how long R1 had been dead inside their apartment. Shortly after this incident, and prior to CCLD’s commencing its complaint investigation, Licensee re-implemented a daily checklist procedure. The daily checklist required staff to perform either a welfare phone call or visual check on every resident, no matter how independent they are, if said resident in a day did not make a dining room appearance at breakfast, lunch, or dinner, or had not been seen in a common area. Per interviews of managers and frontline staff, this checklist procedure existed at the facility at an earlier point in time, but Licensee had stopped using it from January 2022 through 05/17/2022.

Regarding the bathing allegation, the Complainant said dependent residents were not consistently receiving caregiver assistance their scheduled showers. Interviews of managers and frontline staff, corroborated by shower schedules, showed that most residents of the facility were supposed to receive shower/bathing assistance twice (2) per week. One facility manager told CCLD they discovered some caregivers charted/documented that a resident refused a shower, when in fact staff did not have enough time to provide the assistance. There was a noticeable increase in marked refusals during the months when caregiving staffing was severely impaired at the facility. A laundry aide, who sometimes filled open caregiver shifts, corroborated they saw caregivers falsify shower records.

Out of the ten (10) residents CCLD interviewed for this case, two (2) [Resident #2 (R2) and Resident #3 (R3)] relied on and paid Licensee for shower assistance. R2 and R3 affirmed that during the complaint allegation timeframe, caregivers frequently failed to assist them with their own showers, to the point that each gave up on relying on Licensee for such assistance. R2, who was wheelchair-bound, worked with their own physical therapist to learn how to shower themselves. R3’s responsible person hired a third-party agency caregiver to assist R3 shower. Even among the seven (7) resident interviewees who were independent with bathing, three (3) told CCLD that they personally knew of peers (other than R2 and R3) who were not getting bathed by facility caregivers during the allegation timeframe, despite paying Licensee for those services.

[CONTINUED ON LIC 9099-C, 5 of 5]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 11
Control Number 08-AS-20220711144305
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: 04/14/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 4 of 5]

Regarding the allegation about activity programming, the Complainant said Licensee did not offer residents required variety. Review of the facility’s activity calendars for June 2022 and July 2022 showed examples of socialization, daily living skills, leisure time, physical activity, educational, and worship activities. Manager, staff, and resident interviews aligned to show: Facility staff usually carried out the activities listed in the posted calendars. However, those interviews also showed there were many months when facility’s van/bus was out of commission and/or unavailable for resident use. Even when the van/bus was working, Licensee did not offer residents opportunities for “community events such as concerts, tours and plays,” as described in regulation.

Based on records and interviews, a preponderance of evidence exists to show that Licensee did not employ staff in numbers necessary to meet resident needs, that staff did not provide needed observation to R1, that staff did not provide needed bathing assistance to residents, and that Licensee did not provide residents the full required variety of planned activities. These four (4) allegations are therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). Since the facility has closed and ceased operations, no Plans of Correction were formed with the Licensee.

A copy of this report, the LIC9099-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the Licensee’s last known address via USPS certified mail.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 11
Control Number 08-AS-20220711144305
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by:
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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Based on records review and interviews, Licensee did not ensure that facility personnel were at all times sufficient in numbers to provide the services necessary to meet resident needs. This posed a potential health and safety risk to 104 of 104 residents (R1 through Resident #104) in care.
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Type B
04/14/2025
Section Cited
CCR
87466
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87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by:
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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Based on records review and interviews, Licensee did not ensure that 1 of 104 residents (R1) was regularly observed. This posed a potential health and safety 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 11
Control Number 08-AS-20220711144305
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2025
Section Cited
CCR
87464(f)(4)
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87464 Basic Services: “(f) Basic services shall at a minimum include: (4) Personal assistance and care…such as…bathing…” This requirement was not met, as evidenced by:
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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Based on records review and interviews, Licensee did not ensure that at least 4 of 104 residents (R2, R3, R4, and R5) received personal assistance and care with bathing. This posed a potential health and personal rights risk to persons in care.
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Type B
04/14/2025
Section Cited
CCR
87219(c)(3)
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87219 Planned Activities: “(c) The licensee shall arrange for utilization of available community resources…which may include: (3) Community events such as concerts, tours and plays.” This requirement was not met, as evidenced by:
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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Based on records review and interviews, Licensee did not arrange for utilization of available community resources to include community events such as concerts, tours and plays.” This posed a potential personal rights risk to 104 of 105 residents (R1 through Resident #104) 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 11
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
07/11/2022 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20220711144305

FACILITY NAME:PACIFICA SENIOR LIVING BONITAFACILITY NUMBER:
374604177
ADMINISTRATOR:MARKOVICH, PAULFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:0CENSUS: 0DATE:
04/14/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:N/A. Report Certified Mailed to Licensee.TIME COMPLETED:
07:00 PM
ALLEGATION(S):
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-Staff did not empty trash containers, as required.
-Licensee did not meet COVID-19 response testing requirements, following a positive case.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior complaint allegations. Since the facility ceased operations on 01/19/2023 due to Change in Ownership, these allegation findings were delivered to the Licensee via USPS certified mail.

The Complainant alleged that Licensee’s staff did not empty residents’ trash containers as required, and that Licensee did not meet response testing requirements during the facility’s May 2022 COVID-19 outbreak. CCLD’s investigation involved an unannounced facility tour/welfare check and review of pertinent facility care records and outside agency reports. The Department also interviewed four (4) facility managers, eight (8) frontline staff, ten (10) residents, and one (1) outside source, each of whom was relevant to the facility during the complaint allegation timeframe.

[CONTINUED ON LIC 9099-C, 1 of 2]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 9 of 11
Control Number 08-AS-20220711144305
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: 04/14/2025
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[CONTINUED FROM LIC 9099-A]

Nine (9) out of ten (10) residents interviewed by CCLD said they did not have concerns/complaints about the frequency with which staff emptied the trash cans inside their rooms. During his site visit on 07/18/2022, LPA did not see evidence of overflowing trash cans or the like.

According to CCLD Provider Information Notice (PIN) 22-07-ASC, COVID-19 “fully vaccinated” was defined as persons who were “two weeks or more after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization), or two weeks or more after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Janssen).” According to the facility’s COVID-19 vaccination records: During the allegation timeframe, there were around 103 residents and 45 staff. Around 79 residents (76.69%) met the criteria for being fully vaccinated. Around 35 staff (77.78%) met the criteria for being fully vaccinated. According to CCLD PIN 22-16-ASC, which was in-force during the allegation time frame: In facilities where either less than 90% of residents or less than 90% of staff were fully vaccinated against COVID-19, whenever a COVID-19 positive resident or staff was identified, Licensees were required to COVID test all remaining residents and staff (and not just “close contacts”) every 3 to 7 days, and to keep retesting them until “no new cases are identified in sequential rounds of testing covering a 14-day period.”

Per notes of CCLD’s past phone calls with Licensee, and the line listing of positive cases which Licensee shared with San Diego County Public Health: The May 2022 COVID-19 outbreak at the facility began after three (3) staff tested COVID-positive on 05/15/2022. On 05/22/2022, eleven (11) residents in the memory care section tested positive. On 05/25/2022, two (2) residents in the assisted living section tested positive. On 05/26/2022, two (2) more staff tested COVID-positive. On 05/28/2022, two more (2) residents tested COVID-positive. On 06/04/2022, one (1) more staff tested COVID-positive. On 06/09/2022, one (1) more resident tested COVID-positive. There were no successive COVID-positive persons that were part of the original May 2022 outbreak.


[CONTINUED ON LIC 9099-C, 2 of 2]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 10 of 11
Control Number 08-AS-20220711144305
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: 04/14/2025
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[CONTINUED FROM LIC 9099-C, 1 of 2]

Interviews of managers, staff, residents, and outside sources widely corroborated: Licensee was faithful in observing public health requirements regarding Personal Protective Equipment (PPE), disinfection, and isolation of COVID-19 positive cases. Licensee typically conducted, to the best of its ability, facility-wide testing (and not just “close contacts”). Licensee used a combination of PCR and rapid-antigen tests. PCR tests were mailed to an offsite third-party laboratory for processing, while rapid-antigen test results were available to staff within fifteen minutes. Most tests used by Licensee were of the rapid-antigen type and were negative. Laboratory records showed additional PRC tests were run during the above outbreak resulting in negative test results. During his site visit on 07/18/2022, LPA saw plenty of reserve COVID-19 testing kits on premises.

Based on records and interviews, a preponderance of evidence does not exist to show that Licensee’s staff did not empty residents’ trash containers as required, or that Licensee did not meet response testing requirements during the facility’s May 2022 COVID-19 outbreak. Both allegations were therefore Unsubstantiated, and no deficiencies were cited for them.

A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the Licensee’s last known address via USPS certified mail.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 11 of 11