374604757-8-19-2025-08-AS-APAO-DKSTP4-20250822145344

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604757
Report Date: 08/06/2025
Date Signed: 08/19/2025 02:14:46 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
07/29/2025 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20250729152529

FACILITY NAME:	IVY PARK AT BONITA		FACILITY NUMBER:	374604757
ADMINISTRATOR:	NEWTON, RANDAL		FACILITY TYPE:	740
ADDRESS:	3302 BONITA ROAD		TELEPHONE:	(619) 470-2220
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	96	CENSUS: 60	DATE:	08/06/2025
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Randal Newton		TIME COMPLETED:	03:18 PM

ALLEGATION(S):

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Staff did not dispense medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit and also delivered findings regarding the above complaint allegation. LPA introduced himself and disclosed the purpose of the visit with Executive Director Randal Newton.

On July 29, 2025 it was alleged that staff did not dispense Resident 1 (R1) medication as prescribed. It was reported that medications obtained for R1 were found to still be in "pill packs" or bottles despite instructions indicating that they were to be dispensed to R1 several times a day. It was specifically reported that R1 had a full bottle of acetaminophen which should have been dispensed. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff and records review.

LPA interviewed Staff 1 (S1) who works both in the assisted living and the memory care unit. S1 stated that medication refills are requested by facility staff 80 percent of the time while 20 percent of the time it is requested by the resident's responsible party.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

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 3

Control Number 08-AS-20250729152529

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: IVY PARK AT BONITA	FACILITY NUMBER: 374604757
	VISIT DATE: 08/06/2025

NARRATIVE

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S1 stated that their are various reasons a medication would not be dispensed to a resident, but regardless of the reason it is always logged in the MARs. S1 stated that when they dispense medication to a resident, everything has to be "grayed" out on the computer system, meaning the medication was logged and charted and they can move on to the next resident for "med-pass."

LPA interviewed Staff 2 (S2) who stated that they have worked at the facility for over four years. S2 stated that they work both in the memory care unit and assisted living. S2 stated that whenever a resident is not given their medication the reason is logged in the "system." S2 stated that their would never be a time when a staff member would not log in a medication that was not dispensed. S2 stated that S2 meets every week with unit directors to discuss the "exceptions" or the medications that were not dispensed and "trends." S2 stated that the facility recently changed pharmacies which caused a delay on receiving various medications for residents. S2 stated that R1 has not had any medication errors or missed medication. S2 stated that S2 personally investigates and writes incident reports anytime their is a medication error. S2 stated that they review and discuss the medication error with the unit directors and notify the Executive Director.

LPA interviewed Staff 3 (S3) who stated that they have worked at the facility for over 10 years. S3 stated that they dispense medication in both the assisted living unit and the memory care unit. S3 stated that whenever a resident is not given their medication the reason is logged into the computer system. S3 stated that their would never be a time when a staff member would not log in a medication that was not given and the reason. S3 stated that they are familiar with R1. S3 stated that they recall giving R1 their PRN of Tylenol frequently for pain. S3 stated that their were no medication errors or missed medications for R1.

LPA interviewed Assisted Living Director (ALD) who stated that R1 was on eight routine medications and four PRN medications during their stay at the facility. ALD stated that prior to a resident going out in the community it is facility protocol to sign out their medications with the person who is taking the resident. If a resident leaves via emergency services a medication list is printed and given along with medication instructions. ALD stated that staff order medications through their house pharmacy or the through the residents’ responsible party. If a resident chooses not to use the house pharmacy, the responsible party will order and deliver medications to the community upon request. If a resident uses the house pharmacy and they do not have medications on hand, it could be due to needing a new signed order from the Primary Care Physician (PCP) or a delay in delivery from the pharmacy. Facility staff along with the house pharmacy would continue to contact the PCP until the medication order is signed and sent to pharmacy.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20250729152529

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: IVY PARK AT BONITA	FACILITY NUMBER: 374604757
	VISIT DATE: 08/06/2025

NARRATIVE

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LPA Interviewed Memory Care Director (MCD) who stated that R1 was out of the facility several times. On one of those dates R1 had a fall while with their Responsible Party (RP). Upon return R1 was evaluated and given medications. MCD stated that in June 2025 the house pharmacy was being changed. MCD stated that they advised RP that medication refills needed to be done outside of the community. RP advised MCD that PCP sent the medications to a pharmacy in Los Angeles in error. MCD and RP were in regular communication and RP advised MCD that they would order and deliver R1’s medications. Facility would advise RP when refills were needed. MCD advised RP that R1 had a new order of Tylenol with a higher dosage which meant they would no longer dispense the remaining Tylenol. MCD personally signed out R1’s medications to RP. MCD stated that they advised RP that they were giving RP more medication “just to be safe.” RP agreed with MCD. MCD stated per facility protocol they gave RP a copy of medication list and release form.

LPA reviewed staff schedules dated May 2025 through July 2025. Staff schedule for assisted living revealed an average of three to four caregivers, two LVN’s and one med tech for the “AM” shift. The “PM” shift had an average of three to four caregivers and one med tech. The assisted living average census was 40 residents. The memory care “AM” staff schedule revealed an average of four caregivers, one med tech and one “floating” LVN. The memory care “PM” schedule revealed an average of four caregivers and one LVN. The memory care average census was 20 residents. LPA reviewed Medication Administration Records (MAR's) for R1 for the dates of May 1, 2025 through July 31,2025. A Doctor's order for Acetaminophen was received on June 13,2025. Acetaminophen was a "PRN" which would be dispensed as needed. LPA reviewed R1's charting notes dated May 2025 through July 2025. On multiple dates R1 denied any pain and discomfort. During the month of July R1 had falls and an injury which the PRN was given more frequently. Review of R1's MAR's found that all of the medications were dispensed as prescribed. The dates that the medications were not dispensed were due to; resident refusal, out in the community or medication not available. The MAR's was logged properly with dates and staff initials. No records were found to show that a medication error had occurred. Review of internal charting notes revealed regular communication with R1's Physician regarding medication and care needs.

Based on interviews, LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Randal Newton, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. This is an amended version of the original report created on August 6, 2025.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

LIC9099 (FAS) - (06/04)

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