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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604757
Report Date: 10/23/2025
Date Signed: 10/23/2025 05:12:01 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
12/23/2024 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20241223134527
FACILITY NAME:IVY PARK AT BONITAFACILITY NUMBER:
374604757
ADMINISTRATOR:NEWTON, RANDALFACILITY TYPE:
740
ADDRESS:3302 BONITA ROADTELEPHONE:
(619) 470-2220
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:96CENSUS: 66DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Randal NewtonTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff was abusive towards resident
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 December 23, 2024 it was alleged that Staff 1 (S1) was abusive towards Resident 1 (R1). It was reported that R1 stated " I think something happens to me when I'm with S1. When asked to further explain, R1 stated " I don't know." R1 was asked if they were safe. R1 stated, "yes, I'm ok.". The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, resident's, outside parties and records review.

Records review revealed R1 has a diagnosis of senile degeneration of the brain, vascular dementia and major depressive disorder. R1 is also confused and disoriented at times.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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 3
Control Number 08-AS-20241223134527
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: 10/23/2025
NARRATIVE
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LPA interviewed R1 on December 26, 2024 at the facility. R1 was observed to be using a wheelchair. R1 stated that they were doing well. In regards to the facility, R1 stated "It's okay for me" LPA asked R1 how it could be better, R1 stated if their spouse were there and still alive. R1 stated that the staff are "fine, they're ok" LPA asked R1 if any staff member has ever yelled at them or hit them, R1 stated no. LPA asked R1 if they were familiar with S1. R1 stated yes. LPA asked R1 if S1 has ever yelled at R1, R1 stated no. LPA asked R1 if S1 had ever hit or physically abused them, R1 stated no, never. LPA asked R1 if they had any issues or concerns they would like to share. R1 stated no, I have no concerns or issues to share.

LPA interviewed Resident 2 (R2) on December 26, 2024 at the facility. R2 stated that they were "doing well" R2 stated that they "like it here" LPA asked why? R2 stated that everyone is very nice. LPA asked R2 if they know S1. R2 stated yes. LPA asked R2 how they felt about S1. R2 stated that S1 is very nice and S1 regularly helps R2 with their wheelchair and other personal needs. R2 stated that R2 has never witnessed or heard of S1 abusing or being unkind to another resident.

LPA interviewed Resident 3 (R3) on October 23, 2025, R3 stated that they recently came back from a skilled nursing facility and they were happy to return. R3 stated that they "love it at the facility." R3 stated that the food is great and the residents and staff are all friendly. R3 stated that they know S1. R3 stated that S1 is very hardworking and is always "bouncing around." R3 stated that S1 will help you with anything. R3 denied any verbal or physical abuse by S1 or any other staff member.

LPA interviewed S1 who stated that they have worked at the facility for over one year. S1 stated that they work the "PM shift." S1 stated that some of their job duties include showering residents and preparing them for bedtime. LPA asked S1 if they have ever had any issues with resident's in the past. S1 stated that only with R1. S1 stated that R1 can be very aggressive and difficult at times. S1 stated that R1 will sit in the lobby area and complain all day. S1 stated that they have witnessed R1 be rude with other facility staff as well. S1 denied any physical or verbal abuse towards R1.

LPA interviewed Staff 2 (S2) at the facility. S2 stated that they are R1's main caregiver and they know R1 very well. S2 stated that R1's dementia has gotten worse recently and R1 does not remember names, only faces. S2 stated that R1 has a lot of mood swings throughout the day. S2 stated that R1 is "hit or miss," R1 is either really happy to see you or R1 wants you to leave them alone. S2 stated that they have witnessed R1 sitting in the lobby area telling people to "shut up."

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

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20241223134527
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: 10/23/2025
NARRATIVE
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LPA interviewed Staff 3 (S3) at the facility. S3 stated that they interact with R1 on a regular basis. S3 stated that R1 does not like to hear sounds and will regularly tell others to "shut up." S3 stated that immediately after R1 eats their meals in the dining area R1 demands staff to move R1 to the lobby area without delay. S3 stated that since R1 has to wait a few minutes for staff to move R1 to the lobby area, R1 becomes upset and has yelled at staff in the past. S3 denied ever witnessing or any knowledge of staff members being abusive towards R1.

LPA interviewed outside source (OS) regarding the complaint allegation. OS stated that R1 is not in their right mind. OS stated that they recently visited R1 and assist R1 with bill pay. OS stated that R1 is clinically depressed, gets agitated and thinks things happen, that never happened. OS stated that R1 advised them last week that they fell. OS confirmed with the facility that R1 did not fall. OS stated that R1 can be very difficult if R1 does not like someone. OS stated that they are aware that R1 had issues with S1 in the past. OS stated that they do not believe that S1 physically or verbally abused R1.

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.

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

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3