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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604544
Report Date: 03/29/2023
Date Signed: 03/29/2023 11:56:49 AM


Document Has Been Signed on 03/29/2023 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 BONITAFACILITY NUMBER:
374604544
ADMINISTRATOR:MARKOVICH, PAULFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:145CENSUS: 97DATE:
03/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Business Office Manager Rebecca Toves and Executive Director Emily DeLaBarreTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Business Office Manager Rebecca Toves. LPA also met with Executive Director Emily DeLaBarre, who arrived later during the visit.

Today's visit was in response to a self-reported LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 03/27/2023. Per the report: on 03/20/2023, Resident #1 (R1) had an AWOL (absent without leave) incident. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] Facility staff did not see or hear R1 leave. Upon recognizing R1 was missing, staff unsuccessfully searched the facility building and surrounding areas before calling law enforcement. R1 was found a few hours later by personnel at a neighboring business, who returned R1 to the facility unharmed/uninjured.

During today’s visit, LPA briefly toured the facility and performed a welfare check on R1, verifying that they were indeed unharmed/uninjured. LPA interviewed R1 and relevant staff. LPA also reviewed pertinent administrative, care, and medical records.

According to R1’s latest LIC602 Physician’s Report (dated 02/01/2023), to the stock question about whether R1 was “able to leave the facility unassisted,” their doctor checked “yes.” However, the same doctor also diagnosed with R1 with “Mild Cognitive Impairment,” indicated they were wheelchair-dependent, and noted they could not independently manage cash or medications. Manager interviews confirmed that prior to the incident in question, R1 was assessed as not able to safely leave the facility unassisted. During interview, LPA observed that R1 was wheelchair-bound and disoriented to time and place (i.e., R1 was unable to state the city they were in, unable to state the year, and unable to name the U.S. President). Due to their baseline disorientation, R1 was not able to participate as a reliable historian/interviewee in this investigation.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 374604544
VISIT DATE: 03/29/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

According to the facility’s own absentee notification plan (i.e. “Clinical Policy & Procedure Manual – California, Clinical 10 – Elopement”): all residents are screened prior to admission to determine their elopement risk. In the event a resident is believed to be missing, “an immediate systematic search of the property and surrounding neighborhood will take place,” and “law enforcement will be notified of [the] elopement within 30 minutes, should the resident not be located.”

According to records and corroborated by staff interviews: On 03/20/2023 around 5:00 AM, Staff #1 (S1) was the first to observe that R1 was not present inside the facility. S1 alerted coworkers, who joined the search. However, it was not until about 7:15 AM that any staff phoned law enforcement for assistance. The neighboring business located R1 in their own parking lot around 7:30 AM, and returned them to the facility around 8:20 AM, concurrent with police officer(s) visiting the facility. CCLD determined that because staff did not follow licensee’s own absentee notification plan, law enforcement resources/reinforcement were delayed by around 1 hour and 45 minutes, which was detrimental to the search for R1. Staff interviews confirmed that R1 used their wheelchair to leave the building and that it was raining on the date of the incident.

During today’s visit, LPA observed a perimeter exit door located within a first-floor stairwell (i.e., “Stairwell 1 Exit Route”), which leads directly outside. Neither the door to access this stairwell, nor the door within it which leads outside, were equipped with an “auditory device or other staff alert feature.” Per manager interviews, aside from R1, there also exist other current residents with memory impairment (and for whom exiting would present a hazard), who have direct access to the perimeter door in question.

Deficiencies were cited per California Health and Safety Code and California Code of Regulations, Title 22. (Refer to the attached LIC 809-D). Plans of Correction were jointly developed with DeLaBarre.

An exit interview was conducted with Toves, to whom a copy of this report, the LIC 809-D, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/29/2023 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 374604544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited

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1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan…”
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Per training records and staff interviews, on 03-24-2023, licensee retrained its staff on the facility's AWOL policy and performed an Elopement Drill with them. These actions resolve the deficiency.
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This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not comply with its absentee notification plan for 1 of 97 residents (R1), which posed a potential safety risk to persons in care.
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Type B
04/28/2023
Section Cited

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87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by:
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Licensee agreed to install either an auditory alert device or other staff alert feature on the perimeter door located within the facility's Assisted Living "Stairwell 1 Exit Route," and to notify LPA (via E-mail or phone) of the installation completion before the POC due date.
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Based on LPA observation, licensee did not have an auditory device or other staff alert feature on one exit door accessible to residents for whom exiting presents a hazard, which posed a potential 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: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3