374604544-3-27-2026-08-AS-RCLK-DTN8N5-20260430223921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 03/27/2026
Date Signed: 03/27/2026 04:04:51 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
03/20/2026 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20260320163909

FACILITY NAME:	BONITA VILLA SENIOR LIVING		FACILITY NUMBER:	374604544
ADMINISTRATOR:	REBECCA TOVES		FACILITY TYPE:	740
ADDRESS:	3434 BONITA ROAD		TELEPHONE:	(619) 476-9444
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	145	CENSUS: 91	DATE:	03/27/2026
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Richard Tibi		TIME COMPLETED:	03:49 PM

ALLEGATION(S):

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Staff abandoned resident at hospital
Unlawful Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit and also delivered complaint findings. LPA introduced himself and disclosed the purpose of the visit with Resident Services Director Richard Tibi.

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

LPA conducted an investigation into allegations that the facility abandoned Resident 1 (R1) at the hospital and unlawfully evicted them. Information was received indicating that R1 had been medically cleared for discharge from the hospital last week. Transportation was arranged to return R1 to the facility; however, upon contacting the facility, hospital staff were informed that the facility would not accept R1 back.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

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-20260320163909

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: 03/27/2026

NARRATIVE

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Facility staff stated that R1 was now a two person assist, required the use of a restraint, and needed a level of care that the facility does not provide. Hospital personnel indicated that there were no medical orders supporting these claimed changes and that they were prepared to discharge R1 to their home at the facility.

LPA interviewed the Resident Services Director (RSD), who confirmed that R1 is not currently residing at the facility. The RSD explained that the facility declined R1’s return due to what they believed was a change in R1’s care needs. According to the RSD, they received direction from the facility’s corporate medical staff, who advised them that R1 required a higher level of care and should not be accepted back.

LPA reviewed an email chain between facility management and the Director of Community Nurse Support. The nurse support director stated that the facility did not have adequate staffing to meet R1’s needs. These were described as requiring two person transfer assistance, use of a wheelchair with a hemi tray (considered a restraint because R1 cannot remove it independently due to altered cognition and dementia), and assistance with repositioning, which would classify R1 as bedbound according to the facility’s internal standards. The facility claimed that these needs exceeded the level of care they could safely provide.

Through record review and interviews, LPA determined that the facility refused R1’s return without following required eviction procedures. R1 was not given a written 30 day notice, relocation planning assistance, or any of the mandated documentation required by Title 22 and the Health and Safety Code. R1 was medically cleared to return, had an established residence at the facility, and was prepared for discharge; however, the facility’s refusal left R1 at the hospital without a lawful or approved discharge and without a safe relocation plan. The refusal to readmit R1 under these circumstances constitutes unlawful eviction and abandonment.

Based on the information obtained, including interviews and documentation reviewed, the allegations of staff abandoning R1 at the hospital and unlawfully evicting them are substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), were provided to Richard Tibi 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: 03/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20260320163909

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: 03/27/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/30/2026 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	The licensee may evict a resident for one or more of the reasons listed in Section... Thirty (30) days written notice to the resident is required...If, after admission, it is determined that the resident has a need not previously identified...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall readmit R1 if and will issue a compliant 30 day eviction notice with reasons, facts, and relocation assistance. Staff will be trained on eviction requirements, and proof of training and policy updates will be submitted to CCL.
	8 9 10 11 12 13 14	The facility refused to readmit R1 after hospitalization and did not serve any written eviction notice or provide reasons and supporting facts at least 30 days prior to the eviction date. This posed an immediate personal rights risk to 1 of 1 of 91 residents in care.	8 9 10 11 12 13 14
Type A 03/30/2026 Section Cited CCR 87468.1	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee will create a readmission/relocation protocol ensuring residents returning from hospitals receive safe placement and proper discharge planning. Staff will receive personal rights training, and documentation of the protocol and training will be submitted to CCL by the due date.
	8 9 10 11 12 13 14	By refusing R1’s readmission and leaving them at the hospital without a lawful discharge plan or safe relocation, the facility failed to ensure safe, healthful and comfortable accommodations and continuity of care, infringing on R1’s personal rights	8 9 10 11 12 13 14

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: 03/27/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

LIC9099 (FAS) - (06/04)

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