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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 02/20/2026
Date Signed: 02/20/2026 01:39:01 PM

Unsubstantiated


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
08/04/2025 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20250804140626
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: DATE:
02/20/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Richard TibiTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Lack of medical care resulted in serious medical complications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano spoke with Resident Services Director Richard Tibi via telephone to deliver complaint findings.

The Department’s investigation consisted of interviews with staff, residents, outside sources and review of records.

It was alleged that Resident 1 (R1) did not receive medical care in a timlely manner, resulting in serious medical complications. On August 1, 2025, R1 tested positive for COVID-19 at the facility and was placed in isolation per protocol. According to Staff 1 (S1), isolation procedures include welfare checks every two hours, meal delivery, and medication administration. Facility charting notes indicate R1 was informed of their condition.On August 2, 2025, at approximately 8:00 AM, facility records show R1 received medication in their room from Staff 2 (S2).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
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 3
Control Number 08-AS-20250804140626
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: 02/20/2026
NARRATIVE
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 At approximately 8:45 AM, Outside Source (OS) arrived at the facility and requested R1 be sent to the hospital due to chest pain and ongoing COVID-19 symptoms. OS reported finding R1 on the bathroom floor, stating R1 claimed to have fallen. S1 stated they were unaware of any fall occurring. Facility charting notes from Staff 3 (S3 )documented that OS requested hospital transfer due to chest pain and COVID-19 status.

R1 was transported to the emergency department, where medical records indicate they denied chest pain but reported knee pain. Physical examination revealed mild tenderness in the left knee and lung sounds described as rhonchi, which are associated with airway obstruction. R1 was diagnosed with acute COVID-19, dehydration, and acute kidney injury on top of chronic kidney disease. Laboratory results showed elevated creatinine levels, likely due to dehydration. R1 was treated with intravenous fluids and a three-day course of antiviral medication and discharged back to the facility on August 4, 2025. OS agreed to the return because R1 was fearful of change but expressed a preference for palliative care.

On October 9, 2025, the Department interviewed S1. S1 confirmed they were familiar with R1 and reiterated that isolation began on August 1, 2025. They stated welfare checks, meals, and medications were provided during isolation. Staff 1 also confirmed that medication was administered on August 2 at 8:00 AM, shortly before OS arrived and requested hospital transfer. Staff 1 reviewed charting notes indicating OS requested hospital transfer due to chest pain and COVID-19 status. Staff 1 stated they were unaware of any fall occurring.

On February 12, 2026, the Department interviewed OS, who stated they had numerous complaints about the facility, including staffing shortages, lack of qualified caregivers, and inadequate care practices. They also stated that private caregivers informed them R1 was not receiving showers as frequently as expected. OS provided multiple emails and a letter detailing complaints about care and communication, which were previously sent to CCL. OS later stated that since the incident, the facility hired new staff and new management, which significantly improved care. They confirmed they no longer wish to pursue the complaint further.

Based on interviews, facility records, and medical documentation, R1 was isolated and received medication according to facility protocol. Charting discrepancies were noted, including inaccurate documentation of communication with OS. Concerns regarding hydration, isolation, and personal care could not be fully verified.

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

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250804140626
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: 02/20/2026
NARRATIVE
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Medical records confirm R1’s complications were primarily related to COVID-19 and underlying health conditions rather than lack of care. Therefore, the allegation that lack of medical care resulted in serious medical complications is unsubstantiated.The report was discussed and an exit interview was conducted with Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Richard Tibi via certified mail.

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

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3