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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 01/28/2025
Date Signed: 01/28/2025 02:43:39 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
01/24/2025 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20250124144319
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: 128DATE:
01/28/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Rebecca TovesTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff did not meet resident's medical needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Rebecca Toves and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review and interviews with facility staff, resident and outside sources.

It was alleged that facility staff did not meet Resident 1's (R1) medical needs. It was reported that R1's oxygen tank was not with R1 for several days.

LPA interviewed R1 and observed R1's oxygen tank was nearby but R1 was not wearing it. R1 stated that they know they're suppose to be wearing the oxygen all day but they often remove it since R1's nose gets sore.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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 4
Control Number 08-AS-20250124144319
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: 01/28/2025
NARRATIVE
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LPA asked R1 if the facility staff remind them to put it back on. R1 exclaimed "oh yeah, they remind me all the time." R1 stated that they did not have their oxygen tank when they moved to their temporary room. R1 stated that they could not remember how many days they did not have their oxygen. R1 further stated that the staff probably forgot about it, since R1 never mentioned it to them.

LPA interviewed outside agency (OA) who stated that R1 arrived at the emergency room with a low oxygen saturation. OA stated that R1 is required to be on oxygen 24/7.OA stated that the facility was treating R1's room for bed bugs and as a result, R1 was transferred to a different room. OA further stated that staff member 1 (S1) advised OA that R1 was moved to their temporary room without their oxygen tank. S1 further stated that since the room was being treated, staff could not enter the room to retrieve it. OA believes R1 was without their oxygen tank for several days.

LPA interviewed R1's responsible party (RP) who stated that R1 has lived at the facility approximately four years. RP stated that R1 is a "pain" and stubborn. RP stated that R1 regularly goes against doctor's orders and refuses to wear compression socks and removes their oxygen regularly. RP stated that R1 will throw staff out of R1's room although they are just trying to help.

LPA interviewed S1 who stated that they "do not know what happened" in regards to R1's oxygen tank. S1 stated that R1's oxygen tank was not with R1 prior to being transported to the hospital. S1 explained that R1's room was being treated for bed bugs and facility staff forgot to move R1's oxygen tank to their temporary room. S1 believes that R1 did not have their oxygen on at the time of the move which caused staff to leave the tank in the room. S1 stated that since the room was being treated for bed bugs staff could not enter the room to retrieve the oxygen tank. S1 estimated that R1 was without their oxygen tank for approximately two days.

LPA interviewed staff member 2 (S2) who stated that they assisted in clearing out R1's temporary room. S2 stated that they noticed that R1's oxygen tank was not transferred to the room. S2 stated that R1 was without their oxygen for approximately two days. S2 stated that they believe staff simply "forgot to move it out."







SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20250124144319
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: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/18/2025
Section Cited
CCR
87611(e)
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In addition to Sections 87465(a) and 87464(d), the licensee shall ensure that the resident is cared for in accordance with the physicians orders and that the resident's medical needs are met.
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Executive Director stated that she will conduct an inserivce training focusing on protocol for transferring residents to temporry rooms. Proof of traning will be provided to Community Care Licensing by the POC due date 2/18/25.
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Based upon staff and outside agency interviews. The facility did not ensure that one out of 128 residents in care (R1) have their medical equipment transferred to their room. This posed a potential health risk to 1 of 1 of 128 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.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20250124144319
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: 01/28/2025
NARRATIVE
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LPA interviewed Executive Director (ED) who stated that she was not aware of the incident involving R1 and their oxygen tank until today. ED stated that she was out of the office during that time frame and was not advised by staff of the incident. ED further stated that facility staff should be aware of R1's need for oxygen since R1 has an "oxygen sign" posted outside of their door.

Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D.

An exit interview was conducted with Rebecca Toves and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Rebecca Toves whose signature below confirms receipt of documents.




SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4