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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:09:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
02/09/2024 and conducted by Evaluator Alyssa Ramirez
COMPLAINT CONTROL NUMBER: 08-AS-20240209104244
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: 117DATE:
08/08/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Resident Service Director Shayla MitchellTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Resident eloped from the facility due to lack of care and supervision
Staff did not follow reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Resident Service Director Shayla Mitchelland discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency.
It was reported to CCL that resident (R1) eloped from the facility due to lack of care and supervision and staff did not follow reporting requirements.

[Continued on LIC 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
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-20240209104244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 BONITA
FACILITY NUMBER: 374604544
VISIT DATE: 08/08/2024
NARRATIVE
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[Continued from LIC 9099]

Regarding the allegation, resident (R1) eloped from the facility due to lack of care and supervision, it was reported that R1 left the facility unattended and sustained a scratch to the arm due to a fall. It was reported that R1 was located but continues to elope from the property. Records review revealed that R1 has a diagnosis of Dementia and is unable to leave the facility unassisted. Records review revealed that facility issued a 30-day notice to R1 due to R1 requiring a higher level of care for exit seeking behaviors. Interviews with staff revealed that R1 has began exhibiting exit seeking behaviors but has never been out of staff sight. Staff report that they will follow R1 when R1 exits the facility and will redirect to come back. Staff reported an incident where R1 was observed with a scratch to the arm but was unable to determine where/how R1 sustained the scratch. No reports of anyone observing R1 off facility property. Staff reported no concerns for lack of supervision. Interview with R1 reported that they have never been out of the facility unassisted and reported that staff will accompany if they want to go for a walk. R1 reported having no concern for lack of supervision and reported that staff are “helpful”. R1 stated they do not recall an incident where they fell and sustained a scratch to the arm. Interview with outside source revealed no concern for the facility.

Regarding the allegation, staff did not follow reporting requirements, it was alleged that facility staff were instructed my management not to report an incident where resident was AWOL (absent without leave) from facility. Interview’s with staff revealed that staff have never been instructed by management not to report something. Facility staff reported that there was some confusion amongst staff about what is considered a reportable AWOL and what is not. Facility reported that staff were re-trained on AWOL procedures, and it was made clear that once a resident is not being supervised by a staff member it is considered an AWOL.

Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today.

An exit interview was conducted with Mitchell. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Mitchell whose signature below verifies receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2