374604544-4-2-2024-08-AS-SJAB-D4LQ9V-20240423115859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:37:37 PM

Substantiated

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
01/18/2024 and conducted by Evaluator Alyssa Ramirez

COMPLAINT CONTROL NUMBER: 08-AS-20240118142103

FACILITY NAME:	PACIFICA SENIOR LIVING BONITA		FACILITY NUMBER:	374604544
ADMINISTRATOR:	REBECCA TOVES		FACILITY TYPE:	740
ADDRESS:	3434 BONITA ROAD		TELEPHONE:	(619) 476-9444
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	145	CENSUS: 120	DATE:	04/02/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Executive Director Rebecca Toves		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility staff leave residents in soiled bedding

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Rebecca Toves
On January 18, 2024, Community Care Licensing (CCL) received a complaint alleging facility staff leave residents in soiled bedding.
During investigation, LPA Ramirez reviewed records, toured the facility and conducted interviews of staff, residents and outside sources.
It was alleged that facility staff leave residents in soiled bedding. Interviews with facility staff revealed that there have been concerns for staff leaving residents in soiled bedding. LPA conducted records review and verified that a staff member had received a progressive disciplinary action form for an incident where a resident was left soiled during a night shift.

[Continued on 9099-C]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa Ramirez	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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 3

Control Number 08-AS-20240118142103

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: PACIFICA SENIOR LIVING BONITA	FACILITY NUMBER: 374604544
	VISIT DATE: 04/02/2024

NARRATIVE

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[Continued from 9099]

Based on evidence obtained, the preponderance of evidence standard was met, therefore, the allegation was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Executive Director Rebecca Toves.

An exit interview was conducted with Toves, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa Ramirez	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240118142103

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: PACIFICA SENIOR LIVING BONITA	FACILITY NUMBER: 374604544
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/02/2024 Section Cited CCR 87625(b)2	1 2 3 4 5 6 7	Managed Incontinence - Licensee shall be responsible for ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Facility records show that residents often wake up with soiled diapers and linen.	1 2 3 4 5 6 7	Administrator shall retrain staff on proper incontinence care and hold them responsible for complying with these requirements. A copy of this training shall be provided to CCL by POC date indicating the date, topic, and attendees.
	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
	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) 767-2306
LICENSING EVALUATOR NAME: Alyssa Ramirez	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC9099 (FAS) - (06/04)

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