374604544-12-22-2025-08-AS-RCLK-DQRSDP-20260128124728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 12/22/2025
Date Signed: 12/22/2025 03:19:00 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
03/28/2024 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20240328170333

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: 99	DATE:	12/22/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Richard Tibi		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Lack of supervision resulted in resident on resident abuse

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced visit to deliver complaint investigation findings for an investigation conducted by LPA Carmen Lopez. LPA identified himself and stated the purpose of the visit and reviewed the findings of the complaint with Resident Services Director Richard Tibi.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, and records review of relevant documents pertinent to this investigation. On March 28, 2024, it was said that there was a lack of supervision that resulted in resident-on-resident abuse.

A review of facility records revealed that a Report of Suspected Dependent Adult/Elder Abuse (SOC341) and an Unusual Incident/Injury Report dated March 22, 2025, documented that Resident #1 (R1) entered Resident #2’s (R2) room without permission, slapped R2 with an open hand, and broke R2’s glasses.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

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 4

Control Number 08-AS-20240328170333

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: 12/22/2025

NARRATIVE

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R1’s physician’s report (LIC602) dated November 9, 2022, indicated that R1 is ambulatory and has an underlying medical condition that is described as a progressive brain disorder leading to memory loss, confusion, language problems, and personality changes, per Google AI overview. The report further stated that R1 required full supervision and assistance with activities of daily living. Their underlying medical condition was described as permanent and severe. R2’s LIC602 further describes their mental condition as confused, disoriented, exhibiting inappropriate behaviors, intermittent aggression, wandering, and sundowning. R1’s preplacement appraisal dated November 28, 2023, noted episodes of confusion and the need for R2 to have special observation and night supervision due to wandering.

R2’s LIC602 was also reviewed. R2 was non-ambulatory and is a fall risk. They have an underlying condition that, per AI overview, is described as a condition where cells, tissues, or organs progressively break down and lose function over time, which affects their nervous system. They are also diagnosed with a condition that affects their memory. Their LIC602 further shows that R2 is able to follow instructions, communicate their needs, and store their own medications.

Resident interviews were conducted. An interview with R1 was attempted but was unsuccessful due to limited verbal skills; R1 only smiled and did not verbally respond. R2 was interviewed and corroborated the incident, stating that R1 entered their room, ignored verbal redirection, slapped them with an open hand, and knocked their glasses off their face. Staff responded to the incident and contacted law enforcement.

Staff interviews were conducted. Staff member S1 corroborated the incident, explaining they had left R2’s room briefly to assist another resident. Upon their return, they found R2 crying and were informed that R1 had entered the room and slapped them. S1 observed R2’s glasses knocked off. S1 reported that R1 has exhibited escalating aggressive behaviors, including attempts to hit caregivers and urinating in random areas. Former Executive Director Rebecca Toves arranged for a one to one caregiver contracted by the VA to assist R1 three times per week following the incident.

Interviews with outside sources were also conducted. One outside source stated that staffing at the facility was adequate but limited, remarking that “they can only do so much.” Another outside source confirmed that R1 received VA assistance after the incident.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20240328170333

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: 12/22/2025

NARRATIVE

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Law enforcement corroborated that they had responded to the facility on multiple occasions for incidents involving R1, including altercations with other residents resulting in minor injuries. R1 was described as frequently getting into altercations and sometimes becoming violent.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff, resident, and outside source interviews, and records review, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D.

The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with RSD Richard Tibi, to whom a copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20240328170333

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: 12/22/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/26/2026 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse… this requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they will conduct a staff training regarding resident on resident altercaions to prevent from occuring again. LIcensee will submit signed training log to LPA by POC dated 1/26/25.
	8 9 10 11 12 13 14	Based on interview and records review, facility staff did not protect one resident (R2) from physical abuse by a resident with a known history of aggression (R1), which posed an immediate health, safety and personal rights risk to 2 of 99 residents in care.	8 9 10 11 12 13 14	The LIC9099-D page was amended to correct deficiency type and verbiage.
	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.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC9099 (FAS) - (06/04)

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