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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 04/11/2023
Date Signed: 04/11/2023 01:39:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/09/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230309132036
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: 104DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director Emily DeLa BarreTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility did not issue resident a refund
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Emily DeLa Barre

On March 9, 2023, Community Care Licensing (CCL) received a complaint alleging facility did not issue resident a refund. According to allegation facility withheld Resident 1’s (R1) prorated community fee and did not issue a refund of such fee. During the investigation, LPA Strong collected pertinent facility records and conducted interviews. Records show that R1 paid a two-thousand-dollar community fee prior to admission. Admissions agreement revealed that if residents leave facility during second month of residency, they are eligible to a refund of sixty percent of the Community Fee after a five-hundred-dollar fee is deducted. According to records collected R1’s moved into facility on November 19, 2022, and moved out on December 24, 2022, due to needing a higher level of care. Records also revealed R1’s room was cleared of belongings as of December 30, 2022. Based on this information R1 was eligible to a seven-hundred-dollar refund.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
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-20230309132036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/11/2023
NARRATIVE
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Interview with outside source revealed that R1 has not been issued a refund as of March 14, 2023. Interview with staff revealed that a refund was requested and it was declined on February 9, 2023, by the accounting office. Additional staff interviews corroborated that R1 had not been issued a refund of the community fee.

Based on interviews, and records reviewed a preponderance of evidence exists to support the allegation. A deficiency is cited per Health and Safety code (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Emily De La Barre, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230309132036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2023
Section Cited
HSC
1569.652(c)
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H&SC 1569.652(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual… within 15 days after the personal property is removed.
This requirement was not met as evidenced by:
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Administrator agrees to read and train all management staff regarding refunds and communicate regulation to accounting department by 4/25/2023. Administrator will submit proof of such training and communication to LPA.
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Based on interviews and records reviewed the licensee did not did not issue a refund within 15 days after personal property was removed for 1 in of 99 persons in care [R1] which posed a potential health and 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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/09/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230309132036

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: 104DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director Emily DeLa BarreTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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2
3
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5
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9
Facility did not inform resident/authorized representative of rate change
INVESTIGATION FINDINGS:
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5
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9
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Emily DeLa Barre.

On March 9, 2023, Community Care Licensing (CCL) received a complaint alleging facility did not inform resident and authorized representative of rate change. According to the allegation Resident 1’s (R1) level of care rate was changed without informing responsible party. During the investigation, LPA Strong collected pertinent facility records and conducted interviews. Records collected revealed that R1 was admitted to facility on November 18, 2022, with an assessment level 2 care. Interviews with outside source revealed R1 was receiving level 2 care. Interview with facility staff revealed facility accounting had an error within the fee ledger charging a level 3 care rather than a level 2. Interview with Administrator corroborated that R1’s rate change was not increased. Records reviewed corroborated that R1 was erroneously charged level 3 care, though records show charge was adjusted to correct level 2 care. Interview's revealed payments for incorrect level

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230309132036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/11/2023
NARRATIVE
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Continued from LIC 9099-A

were not paid.

Based on LPA's interviews and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Emily De La Barre, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5