374604544-11-27-2023-08-AS-SJAB-CY3SVA-20231130131227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 11/27/2023
Date Signed: 11/27/2023 01:00:45 PM

Substantiated

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
10/27/2023 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20231027120157

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: 109	DATE:	11/27/2023
		UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Executive Director Rebecca Toves		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff did not ensure that resident room notification is working properly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Rebecca Toves and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA direct observation and interviews with facility staff and residents.

It was reported to CCL that Resident 1's (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident.) call pendent was broken and R1 was unable to get staff's assistance. LPA visited the facility on November 1, 2023. LPA escorted by facility staff went to R1's room. Facility staff pressed R1's pendant button and a red light blinked. Facility staff advised LPA that the blinking light meant the pendant button was working. LPA was then escorted to the Pendant button control room to verify on the computer that the pendant button was activated.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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-20231027120157

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: 11/27/2023

NARRATIVE

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Facility staff was unable to retrieve the pendant information via computer so facility staff asked a caregiver to press R1's pendant button so we could hear it over the speaker. Several minutes passed and facility staff advised LPA that R1's pendent button was not working. Facility staff replaced R1's pendant button and LPA was able to hear via radio/speaker that R1's pendant button was functional and working.

Facility staff advised LPA that the call button system in the facility was old and has issues at times.

Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D.

An exit interview was conducted with Rebecca Toves and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Rebecca Toves whose signature below confirms receipt of documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20231027120157

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/08/2023 Section Cited CCR 87303(i)(1)	1 2 3 4 5 6 7	Facilities shall have signal systems...All facilities licensed for 16 or more...shall have a signal system which shall:Operate from each resident's living unit.Transmit a visual and/or auditory signal to a central staffed location...loud enough to summon staff. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to do "pendant checks" every week and will conduct a managment training regarding pendant system and will provide proof of training to LPA by POC due date of 12/8/23
	8 9 10 11 12 13 14	Based on LPA direct observation the licensee did not have a functional signal system for R1 [1] of [1] of 109 persons in care which posed a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC9099 (FAS) - (06/04)

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