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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604065
Report Date: 11/05/2025
Date Signed: 11/05/2025 01:19:44 PM

Unsubstantiated


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
06/19/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240619114311
FACILITY NAME:LAGUNA ESTATES SENIOR LIVINGFACILITY NUMBER:
374604065
ADMINISTRATOR:WESLEY LAVENDERFACILITY TYPE:
740
ADDRESS:1088 LAGUNA DRIVETELEPHONE:
(760) 434-7116
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:214CENSUS: 92DATE:
11/05/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kimberly Bonn, Executive DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not assist resident with toileting needs.
Licensee does not ensure sufficient number of staff on site to redirect residents from exiting the memory care unit.





INVESTIGATION FINDINGS:
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On 11/5/2025 at 1pm, Licensing Program Analyst (LPA) Luisa Fontanilla met with Kimberly Bonn via Teams to deliver finding for the above allegations. LPA explained to Bonn the purpose of the meeting.

On June 21, 2024, LPA Liliana Silveira attempted to contact Reporting Party (RP) via email to conduct pre investigation, 10-day visit, interviewed staff and obtained records.
On August 6, 2024, RP contacted LPA Silveira via email and sent a message saying, “Thank You for getting back to me…. Please DISREGARD all my emails at this time regarding Laguna Estates Senior Living.”
The email also indicated a request from RP not to be contacted by LPA.

During the June 21, 2024 visit, LPA Silveira interviewed Resident Services Coordinator (RSC) and Executive Director (ED) Kimberly Bonn. LPA also conducted an inspection of 3 resident rooms including R1’s.

continuation on Lic 9099C


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
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 2
Control Number 08-AS-20240619114311
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: LAGUNA ESTATES SENIOR LIVING
FACILITY NUMBER: 374604065
VISIT DATE: 11/05/2025
NARRATIVE
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con't from Lic 9099

Staff did not assist resident with toileting needs.

Based on LPA Silveira’s observations, bedding, linens, walls and bathrooms were clean. LPA did not observe any stains or fecal matter anywhere in the bedrooms. The bed linens were all clean.



On June 21, 2024, ED states, “Two months ago…. R1 is independent and even though R1 needs toileting assistance, R1 will try to go to the bathroom and do things without staff assistance. Staff have found soiled briefs on the floor and in R1’s walker.”

A review of R1’s Individual Service Plan (ISP) indicates R1 needs total assist with toileting.

Licensee does not ensure sufficient number of staff on site to redirect residents from exiting the memory care unit.

On June 21, 2024, LPA Silveira interviewed ED who states that R1 attempted to exit the facility twice: January 28, 2024, and May 26, 2024. And on those occasions, staff were able to redirect R1 and prevented R1 from exiting the facility.



RSC states that R1’s exit seeking behavior is being addressed by keeping R1 engaged in activities to help decrease elopement tendencies.
At the time of interview, R1 was “put to assist med techs to deliver medications.”

Based on records review and interviews conducted, the above allegations are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No deficiency is noted. A copy of this report was provided to Bonn.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC9099 (FAS) - (06/04)
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