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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604544
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:15:55 PM

Document Has Been Signed on 02/02/2024 03:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 BONITAFACILITY NUMBER:
374604544
ADMINISTRATOR:REBECCA TOVESFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 145CENSUS: 114DATE:
02/02/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director Rebecca TovesTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility Executive Director Rebecca Toves, after identifying herself and stating the purpose of the inspection. This facility serves one hundred fourty five, residents 60 and above. Hospice waiver approved for fifteen.

A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There is a water features in the courtyard made inaccessible to residents. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Overhead as well bedside lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant.

The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in each building. Emergency lighting, and facility telephone were all working. First aid kit(s) were complete and readily accessible in the medical rooms. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Indoor passageways were free from obstructions.

Food supply is replenished frequently by outside vendors. Food was observed to be properly labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts. Medications were labeled and kept in compliance with label instructions.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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 6
Document Has Been Signed on 02/02/2024 03:15 PM - It Cannot Be Edited


Created By: Amy Rodgers On 02/02/2024 at 12:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING BONITA
FACILITY NUMBER: 374604544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 6 out of 8 bathrooms which poses a safety risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Licensee will conduct an inpection of all rooms and place non-skid stips in showers. Licensee agreed to LPA cite inspection to assure non-skid strips are in place.
Type B
Section Cited
CCR
87303(i)(1)(A)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 of 8 rooms inspected which posed a safety risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Licensee will conduct an inpection of all rooms and ensure all pull cords signal system in bathrooms are operational. Licensee agreed to LPA cite inspection to assure opperation of signal system are in place.
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/02/2024 03:15 PM - It Cannot Be Edited


Created By: Amy Rodgers On 02/02/2024 at 12:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING BONITA
FACILITY NUMBER: 374604544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above in 6 of 6 persons which poses a potential and safety risk to 111 of 111 (R1-R111)
POC Due Date: 03/01/2024
Plan of Correction
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Licensee agrees to complete CPR training and first aid training to appropriate care staff to ensure at least one staff member on duty has CPR traiing as well as first aid by POC date. Licensee agreed to cite/record inspection to ensure appropriate staff have first aid certificates and CPR certificates.
Type B
Section Cited
CCR
87415(a)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above in 6 of 6 persons which poses a potential and safety risk to 111 of 111 (R1-R111)
POC Due Date: 03/01/2024
Plan of Correction
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Licensee agrees to have care staff members on night supervision 10:00pm to 6:00 am complete first aid training by POC date. Licensee agreed to LPA cite inspection to assure night staff have first aid certificates.
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/02/2024 03:15 PM - It Cannot Be Edited


Created By: Amy Rodgers On 02/02/2024 at 12:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING BONITA
FACILITY NUMBER: 374604544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above in 6 of 6 persons which poses a potential and safety risk to 111 of 111 (R1-R111)
POC Due Date: 03/01/2024
Plan of Correction
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Licensee agrees to complete first aid training to appropriate care staff to ensure all care staff has as first aid by POC date. Licensee agreed to LPA cite inspection of records to ensure all care staff have first aid.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 of 1 identifiers which poses potential health and safety risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Licensee agrees to rotate emergency food supply and dispose of expired food. Licensee agrees to replenish nonperishable foods to allow for minimum of one week supplies. Licensee agreed to a cite inspection to ensure compliance
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


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Document is an Amendment of Original Document on 03/05/2024 10:40 AM


Created By: Amy Rodgers On 02/02/2024 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 6 of 6 persons which poses/posed a potential safety risk to persons to 111 of 111 (R1-R111) in care.
POC Due Date: 03/01/2024
Plan of Correction
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3
4
Licensee agrees to complete first aid training to appropriate care staff and provide First aid certicates by POC date. Licensee agrees to cite inspections of records to ensure all care staff have first aid
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/02/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a review of In-service training procedures. LPA interviewed Executive Director Toves as well as staff and was assured transportation procedures as well as outside medical and dental assistance procedure are compliant.

There are two large common rooms used for dining and activities. At the time of visit, LPA observed a few residents participating in a small group activity. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

Staff records review verified that all staff records were not complete and compliant. During today’s visit, LPA file review and staff interview, for 6 of 6 care staff (S1-S6) licensee did not have the required First Aid and/or Cardio Pulmonary Resuscitation (CPR) certificates , which posed a potential safety risk to persons in care.

Facility has a two-day supply of perishable food and did not have a seven-day supply of nonperishable food items. Some food supplies were kept in in an locked storage area. During today’s visit, LPA observed storeroom with very limited food supplies. Therefore, did not meet the required one week of nonperishable ‘supplies, which posed a potential health and safety risk to persons in care.

During today’s visit LPA toured residents’ rooms and observed some showers did not have non-skid mats or non-skid strips. This poses a safety risk to persons in care.

An exit interview was conducted with Executive Director Tover to whom copies of this report, Licensee/Appeal Rights (LIC9058 03/22), and 809-D’s were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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