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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604177
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:51:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
02/24/2021 and conducted by Evaluator Daniel Pena
COMPLAINT CONTROL NUMBER: 08-AS-20210224082545
FACILITY NAME:ATRIA BONITAFACILITY NUMBER:
374604177
ADMINISTRATOR:WILLIAMS, REBECCAFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:145CENSUS: 102DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rene Leon II, Executive DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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-Questionable Death
INVESTIGATION FINDINGS:
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On 9/23/2022, at approximately 10:45 AM, Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced visit to the facility to conclude a complaint investigation. LPA was met at the entrance by Executive Leon II. After identifying himself and displaying his department identification, LPA was allowed inside the facility. LPA was met by Executive Director Rene Leon II to whom LPA explained the elements of the complaint.

It was alleged that a resident’s death was questionable. The Department’s investigation consisted of reviews of facility and outside agency records, observation and interviews with staff, responsible persons and outside agency sources. Records and interviews presented that Resident 1 (R1) was found unresponsive on their bed on 2/23/2021 at 11:42 AM. Outside source reports were reviewed and revealed no foul play but also stated that the actual time of R1’s death was unknown. Police reports were reviewed and indicated that no crime had been committed and further investigation was suspended.

R1 had lived at Atria Bonita (Facility #374604177) since their admittance on 12/07/2016. R1 resided in the Independent Living (IL) portion of the facility and did not contract for assistance with any Activities of Daily
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 08-AS-20210224082545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ATRIA BONITA
FACILITY NUMBER: 374604177
VISIT DATE: 09/23/2022
NARRATIVE
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Living (ADL). Records showed that R1 was last assessed on 1/15/2021 further maintaining R1’s independence. R1 was issued an alert pendant to activate in case of an emergency or when assistance was needed. Interviews reported that R1 had the pendant on their person but did not activate it prior to their death. Interviews with R1’s responsible persons confirmed R1 was independent. Facility records indicated that the only services provided to R1 were laundry and trash removal. Meals were offered but R1 ordered food to be delivered or prepared their own meals.

Review of R1’s pertinent medical records showed that R1’s diagnoses included arthritis, rheumatoid arthritis, gastrointestinal reflux, end stage renal disease, obesity, history of fractures (right femur, hip and pelvis), required dialysis, restless leg syndrome, fall history, sepsis due to E.coli, sleep apnea, visual impairment, atherosclerosis, hyperlipidemia and Type 2 diabetes. R1 arranged their own transportation and received dialysis treatment three times per week. R1’s autopsy report listed R1’s cause of death as atherosclerotic cardiovascular disease; manner of death as natural and date and time of death as 02/23/2021 at 11:41 AM. There was no indication of neglect or abuse and no other contributing factors were noted in the reports.

The Department has investigated the allegation that R1’s death was questionable. However, based on the information obtained during the course of the investigation, the finding is determined to be Unsubstantiated. This finding means although the allegation may have occurred or could be valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Director Leon II and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) were provided and Director Leon's signature on this form confirms receipt of these reports.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
02/24/2021 and conducted by Evaluator Daniel Pena
COMPLAINT CONTROL NUMBER: 08-AS-20210224082545

FACILITY NAME:ATRIA BONITAFACILITY NUMBER:
374604177
ADMINISTRATOR:WILLIAMS, REBECCAFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:145CENSUS: 102DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Director, Rene Leon IITIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not conduct safety check on a resident as required
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced subsequent visit to deliver a finding regarding the aforementioned complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Rene Leon II.

It was alleged that staff did not conduct a safety check on a resident as required. The Department’s investigation involved reviews of Resident 1’s [LIC811 Confidential Names provided to Director to identify R1) medical records, facility records, outside source records, facility observation and interviews of pertinent staff and outside sources.

Investigation revealed that, in response to COVID-19, the facility implemented facility policy requiring staff to conduct daily temperature/safety checks of all residents. Interviews and facility records indicated that temperature/safety checks were taken of R1 on 2/21/21 and 2/23/21. Staff reported last seeing R1 awake and alert on 2/21/2021. Interviews and records confirmed staff found R1 deceased in their bed on
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20210224082545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ATRIA BONITA
FACILITY NUMBER: 374604177
VISIT DATE: 09/23/2022
NARRATIVE
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2/23/2021. This investigation revealed a discrepancy regarding R1’s required temperature/safety check on 2/22/21.

Statements disclosed that a former employee, told management that they conducted a temperature/safety check of R1 on 2/22/2021. The former employee admitted to management that they had not in fact conducted a temperature/safety check of R1 as previously stated. The former employee stated their reason for not conducting R1’s temperature/safety check was because they were “busy.” The former employee later recanted their admission saying that they did not falsify their statement and had asked other staff to complete R1’s temperature/safety check. Witness interviews did not corroborate the former employee’s account of the events on 2/22/21. The staff’s employment was terminated on 2/25/2021.

Based on former staff’s admission, resident observation, review of pertinent records and interviews with staff and outside sources, the preponderance of evidence shows that a former employee did not conduct a temperature/safety check of R1 on 2/22/21. The former employee lied by telling management that they did conduct the check. Therefore, the allegation that staff did not conduct a safety check of a resident as required is Substantiated.

This deficiency is cited in accordance to the California Code of Regulations, Title 22, Division 6, Chapter 8, and is noted on the attached LIC9099-D. The Licensee was provided a copy of their appeal rights (LIC9058 01/16), the LIC811 Confidential Names List and their signature on this form, acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided to Director Leon II.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20210224082545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA BONITA
FACILITY NUMBER: 374604177
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General: “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” This requirement is not met as evidenced by:

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The licensee terminated the staff’s employment on 2/25/2021, immediately removing the risk to resident’s health and safety. The licensee has committed to provide vendorized training for all staff on care and supervision and submit a sign-in sheet to LPA by the POC due date.
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Based on interviews and record reviews, the licensee did not employ competent staff to provide the services necessary to meet resident needs for 1 of 92 persons in care (R1), which posed a potential safety or personal rights 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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5