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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 12/23/2025
Date Signed: 12/24/2025 10:15:52 AM

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
06/04/2024 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20240604154836
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: 99DATE:
12/23/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Abraham BotelloTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Questionable Death
Staff did not render services to resident as agreed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano delivered complaint findings to Executive Director Abraham Botello at the San Diego Regional Office conference room.

On June 4, 2024 the Department received a complaint alleging Neglect/Lack of supervision of R1, resulted in Questionable Death. It has also been alleged Staff did not render services to resident as agreed.

The Department reviewed incident report (IR) dated May 29, 2024, regarding R1. The IR stated, on May 22, 2024, around 9:00pm, a resident came down to the lobby and informed staff that R1 was on the floor. Staff went upstairs and assessed R1. R1 expressed their hip pain and would shriek when their hips were touched. 911 was contacted.

On June 11, 2024, the Department interviewed Rebecca Toves, Executive Director (ED). ED stated R1 moved in on November 17, 2023, in the independent living section and initially had no additional status checks.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
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 7
Control Number 08-AS-20240604154836
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: PACIFICA SENIOR LIVING BONITA
FACILITY NUMBER: 374604544
VISIT DATE: 12/23/2025
NARRATIVE
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ED stated by December 21, 2023, R1 was re-assessed for assisted living which indicated that R1 required more assistance with daily tasks.  ED said the caregivers were reporting that R1 was having difficulty keeping their room clutter free and organized. ED stated R1 had a cat and R1 was unable to keep the cat box clean, and the cats water dish was constantly spilling onto the floor causing a fall risk for R1. ED stated housekeeping was cleaning after the cat and making sure the water dish was not spilled on the floor and cleaning R1’s room because their floors were cluttered and they were worried about R1 falling. ED stated by early March 2024, ED and R1’s family decided to schedule daily housekeeping for R1 since they were unable to keep their room clean, mostly due from mild dementia that was progressive and they continued to decline. It was also revealed that R1’s Designated housekeeper (S1) resigned on May 2, 2024 and no additional housekeeping was assigned to R1. ED stated that they were looking to hire extra staff but at that time no one was cleaning R1’s room up  for approximately 19 days leading to R1’s fall, which resulted in a hip fracture. ED stated they were unaware of R1 having any history of falls. ED also said that they were unaware that R1 was on a waiting list for memory care and that they did not follow-up on that. ED said that they were planning to look into what was going on with R, but they had not been able to get to it before R1’s fall, on May 22, 2024. 

  The Department interviewed Resident Care Coordinator, RCC, Stephanie Iffland. RCC said former Residential Service Director (FRSD) Jennifer Brown was working with the family about R1 but abruptly separated from the facility without notes or information regarding the residents. The Department asked RCC with the changes and concerns with R1, why wasn’t R1 re-evaluated, and RCC was unable to answer. RCC admitted that R1 had sustained at least nine (9) falls that they were aware of and felt R1 needed more assistance with their care. RCC also said that housekeeping was being provided daily for R1 but it was not enough because R1 would take everything back out and leave clothes, food, wrappers, and shoes on their bedroom floor. RCC stated the Caregivers also reported that they witnessed R1 eating cat food and urinating in the litter box. RCC said that R1 had a weak knee, many falls and was encouraged to use their pendant for assistance. However, R1 rarely used their pendant and did not ask for assistance. The Department asked RCC if R1 should have been moved to memory care or re-evaluated for possibly a higher level of care. RCC said yes, R1 should have been re-evaluated.  The Department asked why didn’t they schedule another housekeeper to clean R1’s room when the last one quit. RCC said they didn’t know what was going on regarding hiring additional housekeepers and that they were not sure why no one reported the condition of R1’s room.  
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20240604154836
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: PACIFICA SENIOR LIVING BONITA
FACILITY NUMBER: 374604544
VISIT DATE: 12/23/2025
NARRATIVE
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The Department interviewed staff (S1). S1 stated R1 kept taking items out and would tell everyone that they needed to organize their room, but left it a mess. S1 said they would offer to help R1 but they would get upset and irritated and refused any help. S1 also stated during the time of the former RSD, a caregiver reported to them that R1 was eating cat food and staff took it away from them. R1 told caregiver that it was okay to eat cat food, and caregiver suspected that R1 was showing signs of dementia or urinary tract infection, but they were also always confused and did not know where they were most of the time. S1 further stated R1 continued to display forgetfulness and at times was unable to find their room and would be found crying in the hallway until a caregiver found them. S1 said R1 had also bad knees, and often complained of pain and had shortness of breath. S1 said they and other MedTech’s notified former FRSD Jennifer Brown about the changes and concerns R1 was displaying by December 2023. S1 said the family agreed to provide daily housekeeping for R1 but there were days that R1 would not allow housekeeping to come in and clean the room. S1 stated FRSD Brown had mentioned that it appeared that R1 displayed signs of dementia, sundowning and was on the waitlist for memory care and staff was conducting status checks throughout the shift and after meals. 

The Department interviewed Resident Services Director (RSD), Mitchell Shayla Shajun. RSD stated they started working six weeks prior and was picking up where former RSD Jennifer Brown left off. RSD said that Brown did not stay long enough to go over any resident updates or managerial task that needed to be addressed.  RSD stated they were recently made aware of R1’s behavior, and staff shared their concerns regarding R1 eating cat food and going to the bathroom everywhere. RSD stated Staff did not bring up these concerns regarding R1 refusing to shower, or having their briefs changed because R1 had a history of UTI’s (urinary tract infections). RSD said they knew about R1’s mobility issues because they were having a lot of falls. RSD admitted to not following up with family because it was until R1’s fall that these concerns were brought to her attention, and that they knew about the last two falls. RSD believed that R1’s change of condition was discussed with family and they had agreed to placing R1 in memory care. However, RSD clarified that they did not follow-up or look into the matter because they were still in training and learning their position.  

On August 15, 2024, the Department interviewed staff 2 (S2). S2 stated R1’s room was always a mess and malodorous due to the cat box and human and animal feces throughout the studio. S2 also stated caregivers were conducting frequent checks every hour or two to make sure R1 was okay. S2 stated R1 was anxious, depressed and displaying great confusion.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20240604154836
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: PACIFICA SENIOR LIVING BONITA
FACILITY NUMBER: 374604544
VISIT DATE: 12/23/2025
NARRATIVE
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S2 stated R1 was unable to care for themself or their cat. S2 said the staff hid the cat food because R1 would eat it and they told the family not to bring cleaning supplies to R1 because they were worried R1 might do something unsafe with them. S2 also explained that staff had requested to turn off the water to R1’s kitchen sink because they would get water all over the floor and was likely to fall. S2 said R1 had a bad knee, weak legs and a cluttered studio no matter how often housekeeping came to clean. S2 believed that all of this contributed to all of R1’s falls, which occurred in their room.  

On September 16, 2024, the Department interviewed staff 3 (S3). S3 stated they cleaned R1’s room daily, and sometimes three to four times in one day because R1 had a compulsive disorder to move and “organize” their room resulting in unsafe environment. S3 believed R1 needed to be re-assessed and placed in a higher level of care, as they were very confused. Despite R1’s worsening Dementia, R1’s family and facility management were not making any changes or placing them in memory care. S3 also corroborated that R1 had a bad knee, weak legs, and consumed cat food and feces; but no one addressed these concerns. S3 stated R1 refused to shower when they were covered in feces and also did not like changing their briefs when they were soiled. S3 believed that Management should have re-assessed R1.  

On September 27, 2024, the Department interviewed R1’s Family Member, FM. FM said that they had some concerns about the facility because they believed that they were understaffed and unable to provide the care and services that R1 required. FM stated R1 had been diagnosed with Alzheimer’s seven years prior and that they were moved from a sister facility because they could no longer provide the level of care R1 required. FM stated when they moved R1 into the facility, former Residential Service Director Jennifer Brown said they would be able to accommodate R1. FM stated they checked on R1 once a week and reported R1’s room was dirty and cluttered. FM agreed to pay for daily housekeeping, which went well until the housekeeper left, and the facility was unable to hire additional staff to clean R1’s room. FM believed the facility may have forgotten about the agreement when the new Residential Service Director was hired. 

The Department reviewed facility records which included R1’s appraisal and care notes from November 18, 2023- May 29, 2024. According to the record, R1 moved in the facility on 11/17/23 and had 10 falls through 05/22/24. One note dated 5/22/2024 stated R1 had sustained a fall and R1 expressed they were in pain. When staff tried to touch R1’s hip, R1 shrieked. They were a bit shaky, and taken to the hospital. 
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20240604154836
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: PACIFICA SENIOR LIVING BONITA
FACILITY NUMBER: 374604544
VISIT DATE: 12/23/2025
NARRATIVE
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R1’s initial appraisal, completed by former Residential Service Director (RSD) Jennifer Brown, noted that R1 required very limited assistance and was noted to be independent. There was no indication of R1 having Dementia or Alzheimer’s, despite their pre-placement appraisal dated 11/16/23 noting that they had dementia, depression and anxiety. Within a few months R1’s behavior had dramatically changed and staff was reporting that R1 was requiring more assistance and more status checks. Even though R1 was issued a pendant for assistance, R1 rarely used it to call for assistance. The staff conducted two-hour status checks on R1 and housekeeping had been upgraded to daily with no additional cost due to the habitual clutter and trash in R1’s room. The staff had notified the family members as to the daily clutter that R1 had in their room and it became difficult to keep their room clean and cluttered free causing a safety risk. Staff reported that R1’s confusion increased and had found R1 eating cat food from the can. During December 2023 a conference was arranged with R1’s FM and family to discuss the concerns regarding the change of condition with R1. The family agreed to move R1 to memory care however there was no availability and R1 was placed on a waiting list. Former Residential Service Director (RSD) Jennifer Brown left their employment and no follow-up regarding R1 moving to memory care was conducted. The new RSD did not address R1’s change of condition and their condition worsened until their fall resulting in a fracture on May 22, 2024. 

Staff knew R1 was a fall risk and reported this to management, the clutter had been a significant factor to R1’s frequent falls. The facility did not address the falls and implement fall mitigation measures to attempt to prevent R1’s falls. The additional daily housekeeping had ceased due to being understaffed.  
 
On May 22, 2024, R1 had an unwitnessed fall in their room. R1 was assessed and displayed pain and discomfort, staff called 911 and R1 was transported to a Hospital. Following admission, the residents family elected to transition R1 to comfort care rather than pursue operative intervention, after goals of care discussion with palliative care and orthopedics. On May 29, 2024, R1 was discharged and family eventually selected board and care for placement with hospice services. R1 passed away on June 1, 2024. 

There is enough information to support Neglect/Lack of Care and Supervision leading to an unwitnessed fall and sustaining injury. R1’s cause of death was reported by the coroner’s office as complications of left femoral head and neck fracture (a break in the bone at the junction of the femoral head and femoral shaft) due to R1’s fall. R1’s last fall on May 22,2024 was a contributing factor in their death. Therefore, the allegation for neglect/lack of care and supervision contributing to the client’s death is substantiated. 
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 08-AS-20240604154836
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: PACIFICA SENIOR LIVING BONITA
FACILITY NUMBER: 374604544
VISIT DATE: 12/23/2025
NARRATIVE
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Based on interviews and records review, the preponderance of evidence standard has been met therefore the above allegations were SUBSTANTIATED. An immediate civil penalty in the amount of $500 was assessed per Health and Safety Code 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1.  Further Civil Penalties under Health and Safety Code Section 1569.49 are under review by the Department and may be assessed at a later date. 

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Abraham Botello A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), was provided to Abraham Botello at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20240604154836
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: PACIFICA SENIOR LIVING BONITA
FACILITY NUMBER: 374604544
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2025
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights... (a)In addition to… 87468.1… residents… shall have… the following… rights: (4) to care, supervision… that meet their… needs and are delivered by staff… sufficient in numbers, qualifications, and competency… This requirement was not met as evidenced by
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Licensee stated that they will provide a staff training regarding supervision and identifying residents needs and having a staff on call to cover shifts. Licensee will send LPA training itinerary by POC due date.
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Based on interview and record review, the Licensee did not ensure that R1 received care, supervision and services required by their medical condition, resulting in their fall, fracture, and contributing to their death. This posed an immediate Health, Safety, and Personal Rights risk to 1 of 99 persons in care.
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Type B
01/22/2026
Section Cited
CCR
87303
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 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Licensee stated that maintenance director will conduct room audits and train staff on how to report issues to management. Licensee will send training log/audit by POC due date
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Based on interview, the facility did not render housekeeping services to one resident (R1) as agreed. This posed a potential health, safety and personal rights risk to 1 of 99 residents 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: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7