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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604544
Report Date: 06/21/2024
Date Signed: 06/21/2024 11:10:14 AM

Document Has Been Signed on 06/21/2024 11:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PACIFICA SENIOR LIVING BONITAFACILITY NUMBER:
374604544
ADMINISTRATOR/
DIRECTOR:		REBECCA TOVESFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 145CENSUS: 117DATE:
06/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Executive Director Rebecca TovesTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Executive Director Rebecca Toves and discussed the purpose of the visit.

Community Care Licensing received an incident report on 6/19/2024 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 6/13/2024. Staff was driving to the facility and circled the perimeters per usual route. Staff noticed that back gate was ajar and located R1 walking towards the facility. Facility staff were notified of gate being open per alarm on walkies. Staff failed to check back gate and clear alarm.

During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plan of Correction was jointly developed with the Toves. An exit interview was conducted with Sano, to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2024 11:10 AM - It Cannot Be Edited


Created By: Alyssa Ramirez On 06/21/2024 at 10:47 AM
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: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2024
Section Cited
HSC
1569.317

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1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.”
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Executive Director will ensure that a staff training on elopment procedures is conducted and will email sign in sheet to LPA by POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 117 residents (R1), the licensee did not comply with its absentee notification plan. This posed a potential 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:Simon Jacob
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
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