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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 09/01/2026
Date Signed: 09/01/2026 05:52:55 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
09/19/2025 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20250919134549
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: 82DATE:
09/01/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amber RodgersTIME COMPLETED:
04:07 PM
ALLEGATION(S):
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Licensee did not ensure that resident had access to an emergency signal system.
Licensee did not ensure that the facility's telephone system was in working condition.
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 Executive Director Amber Rodgers.

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

It was reported to CCL that during the early morning hours, Resident 1 (R1) was seen on a personal web camera to have fallen in their room. It was reported that attempts were made to reach the facility by phone for an extended period, but no staff answered the calls. The individual attempting to reach the facility then drove to the facility and assisted R1 themselves. It was also reported to CCL that R1 did not have their emergency call pendant on their neck or anywhere accessible in their room at the time of the fall, even though R1 was supposed to have access to one.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
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-20250919134549
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: 09/01/2026
NARRATIVE
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During the investigation, the LPA conducted interviews, made observations, and reviewed information related to the facility’s communication systems and emergency response practices. Information gathered confirmed that R1 had experienced several previous falls, some resulting in injuries, and staff had contacted an outside source for assistance after finding R1 on the floor on multiple occasions. In one instance, R1 had a bruise over their left eye, and staff were unsure whether the bruise was old or new, so they contacted outside assistance.

Resident interviews showed a pattern of delayed or absent responses to call buttons. One resident stated they had to call emergency services on their own because staff did not respond to their call for help. Another resident reported that their neighbor contacted them two months earlier after falling because staff were not responding to their call button. During staff interviews, one staff member explained that the facility’s walkie‑talkie radios had issues in the past where call button alerts would come through as static. They stated that the static made it difficult to hear or recognize when a call button was activated, which could have caused delays in responding. The staff member also stated that the radios were later updated and that they no longer experience that problem. Additional staff confirmed that the wireless night phone had been out of service for at least a week, and they had heard it might have been disconnected due to nonpayment, although they were unsure if this was accurate. Without a functioning night phone, staff could not receive incoming calls, and residents did not have a reliable way to reach assistance overnight.

Information gathered also showed that emergency signal devices were not consistently available or accessible for residents who required them. Based on interviews, observations, and evidence collected during the investigation, the facility did not ensure reliable access to the emergency signal system, and the failure of the telephone system significantly affected the ability of residents and responsible parties to reach staff during emergencies. Based on the information obtained both allegations 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 Amber Rodgers. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), were provided to Amber Rodgers 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: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250919134549
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: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2026
Section Cited
CCR
87303(i)(1)(A)
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(i) Facilities shall have signal systems...(1) All facilities licensed for 16 or more and all residential facilities...(A) Operate from each resident's living unit. This requirement was not met as evidenced by:
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The licensee shall inspect all resident emergency signal devices to confirm they are functional and available, and submit written confirmation to the LPA by 9/4/26.
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 R1 did not have their emergency call pendant on their neck or accessible in their room at the time of the fall, despite being required to have access to an emergency signal device This failure posed an immediate health and safety risk to R1, 1 of 82 residents in care.
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Type A
09/02/2026
Section Cited
CCR
87311
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All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed... This requirement was not met as evidenced by:
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The licensee restored facility phone service and it is currently operational.
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Staff confirmed the facility’s phone had been out of service for at least one week. This failure presented an immediate health and safety risk to 82 out of 82 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.
SUPERVISOR'S NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3