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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 09/01/2026
Date Signed: 09/01/2026 05:53:53 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
06/30/2026 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20260630092808
FACILITY NAME:BONITA VILLA SENIOR LIVINGFACILITY NUMBER:
374604544
ADMINISTRATOR:REBECCA TOVESFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:145CENSUS: 82DATE:
09/01/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amber RodgersTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility does not have suficient staff to provide care and supervision to residents
Lack of supervision resulted a resident fall not being noticed for hours
Staff is not adequadely trained on fire safety
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit and also delivered complaint findings. LPA introduced himself and disclosed the purpose of the visit with Executive Director Amber Rodgers.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA observations,interviews with staff, residents and outside sources.

It was reported to CCL that an outside agency responded to the facility at approximately 5:46 AM for a medical aid. When the outside agency arrived, the front doors were unlocked and no staff were present at the front desk. The outside source (OS) determined that Resident 1 (R1) had fallen during the night and activated their emergency pendant, but no staff responded. R1 remained on the floor for several hours and had urinated on themselves. R1 declined transport after AMA protocol. OS stated that R1 appeared fully oriented and did not show signs of serious injury but was upset that they were left on the floor all night without assistance.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
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-20260630092808
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: BONITA VILLA SENIOR LIVING
FACILITY NUMBER: 374604544
VISIT DATE: 09/01/2026
NARRATIVE
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During the response, OS spoke with the NOC staff member, who explained they were assigned only to the memory care unit and were not supposed to leave that area. The staff member stated, “We don’t have any staff for this part of the building.” OS noted that this NOC staff member was the only worker in the building until a day shift employee arrived around 6:00 AM. OS asked the day shift employee about bedridden residents, and the employee stated they believed there were three but could not accurately identify their locations. This information did not align with the training expectations related to the facility’s application for bedridden fire clearance.

Staff interviews showed inconsistent understanding of resident supervision needs and emergency procedures. One staff member stated that although they personally felt trained in memory care and bedridden resident needs, they did not believe staff in the past were well trained in fire safety or in supporting bedridden residents. Staff stated that overall training varied depending on which employees were working and that not all staff were confident in emergency response. Interview with newly hired Resident Services Director confirmed that they were told by staff they only work in their assigned areas. RSD advised staff they are required to work in every area of the facility if and when needed.

Information gathered also raised concerns about fire safety readiness. Staff were unable to accurately identify bedridden residents, which is essential for evacuation planning and emergency response. Staff statements and observed gaps in knowledge demonstrated that fire safety training was not adequate and did not match the facility’s reported training efforts.

Evidence gathered throughout the investigation also showed that the facility did not have sufficient staff to provide proper care and supervision. The building had only one staff member on duty overnight, who was assigned exclusively to the memory care unit and did not monitor residents in other parts of the facility. As a result, R1’s fall went unnoticed, pendant calls were unanswered, and residents outside of memory care did not receive adequate supervision during overnight hours.

Based on the information obtained both allegations are substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Amber Rodgers. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), were provided to Amber Rodgers 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: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20260630092808
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: BONITA VILLA SENIOR LIVING
FACILITY NUMBER: 374604544
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2026
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...staff shall be employed to ensure provision of personal assistance...
This requirement was not met as evidenced by:
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The licensee currently has an NCC plan/staffing ratio in place with CCL.. The POC will be cleared by LPA.
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There was only one staff member in the building during overnight hours, and they were restricted to the memory care unit. As a result, R1’s fall went unnoticed for hours. This posed an immediate health and safety risk to 1 of 82 Residents in care (R1).
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Type A
09/02/2026
Section Cited
CCR
87468.2
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities... To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers... This requirement was not met as evidenced by:
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The Licensee currently has an NCC plan/staffing ratio in place with CCL. The POC will be cleared by LPA
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There was only one staff member in the building during overnight hours, and they were restricted to the memory care unit. R1’s fall went unnoticed for hours. This posed an immediate health and safety risk to 1 of 82 residents 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: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20260630092808
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: BONITA VILLA SENIOR LIVING
FACILITY NUMBER: 374604544
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2026
Section Cited
CCR
87411(a)(c)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent...(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified... This requirement was not met as evidenced by:
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The licensee shall retrain all staff on fire safety procedures, bedridden resident identification, and emergency response requirements. The licensee shall provide CCL with documentation confirming completion of staff training by 9/3/26.
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Staff interviews showed inconsistent and insufficient knowledge of fire safety procedures. Staff were unable to accurately identify bedridden residents, which is essential for emergency planning. This posed an immediate health and safety risk to 82 out of 82 residents 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: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4