374604544-9-26-2023-08-AS-DPOL-CW5TEL-20230929144008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 09/26/2023
Date Signed: 09/26/2023 08:33:56 PM

Unsubstantiated

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
08/17/2023 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20230817083804

FACILITY NAME:	PACIFICA SENIOR LIVING BONITA		FACILITY NUMBER:	374604544
ADMINISTRATOR:	MARKOVICH, PAUL		FACILITY TYPE:	740
ADDRESS:	3434 BONITA ROAD		TELEPHONE:	(619) 476-9444
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	145	CENSUS: 111	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Business Office Manager, Rebecca Toves		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff mishandled a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver investigative findings. LPA met with Business Office Manager, Rebecca Toves, and shared findings.

The Department investigated the above-listed complaint allegation. The investigation consisted of observations, a review of relevant records, and interviews with facility staff, residents, and outside sources.

On August 17, 2022, Community Care Licensing (CCL) received a complaint alleging that facility staff mishandled a resident (R1) while in care. [an LIC 811 Confidential Names List was provided to staff to identify the resident]. On August 16, 2022, R1 complained of pain in their left wrist. The wrist was observed to be swollen and bruised. It was specifically alleged that R1’s injury was the result of a staff member (S1) [an LIC 811 Confidential Names List was provided to staff to identify the staff member] handling R1 roughly during incontinence care.
(Continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230817083804

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: PACIFICA SENIOR LIVING BONITA	FACILITY NUMBER: 374604544
	VISIT DATE: 09/26/2023

NARRATIVE

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Continue from LIC9099)

Facility staff immediately called 911 and R1 was taken to the hospital, then discharged the same day with a diagnosis of a sprained wrist. During a visit to the facility conducted on August 23, 2023, R1’s wrist was observed with no signs of injury and R1 was able to move their wrist with full range of motion with no pain. Statements obtained during multiple interviews with R1 regarding the alleged incident were inconsistent due to their dementia. A detailed review of R1’s medical records, service care plan, and daily charting notes indicated that due to documented medical conditions, R1 would often get agitated and would act aggressively toward staff. During a visit to the facility conducted on August 31, 2023, R1 was observed during one aggressive episode which caused a self-inflicted minor injury to R1’s foot. Facility staff were able to de-escalate the situation successfully and R1 immediately calmed down. In addition, staff applied first aid care to R1’s foot. A review of facility records disclosed other reported aggressive incidents involving R1 that although R1 was not injured, resulted in minor injuries to a staff member.

S1 and care staff denied the allegation and maintained during interviews they did not know the source of R1’s injury to their wrist. A review of R1’s daily charting notes during the month of August 2023 indicated two other incidents when R1 did not use the call button and staff would find R1 trying to get out of bed using the bed rail as support. Staff communicated the incidents to R1’s medical provider who subsequently made changes to R1’s medications to minimize anxiety and aggressive behavior. Multiple interviews with residents and staff indicated no concerns with S1 mishandling or mistreating residents. Based on observations, record reviews, and interviews with staff and outside sources there was insufficient evidence to support the allegation that S1 mishandled R1.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Business Office Manager, Rebecca Toves, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) was provided at the conclusion of the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC9099 (FAS) - (06/04)

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