Bonita Villa Senior Living

(b) The licensee shall obtain an updated medical assessment when required by the Department. This requirement was not met as evidenced by; R1’s last medical assessment was dated 10/1/2020. The facility did not obtain updated assessments despite repeated falls, hospitalizations, and changes in condition. This posed an immediate health and safety risk to R1.

"Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents...This requirment was not met as evidenced by. The facility did not supervise R1 properly when they reported hitting their head. Staff did not assess R1, did not call 911 for a suspected head injury, and did not complete or document hourly monitoring checks. This posed an immediate health and safety risk to R1.

(e) The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition... to the attention of the appropriate licensed medical professional... Documentation of such communication shall be added...This requirement was not met as evidenced by; The facility did not conduct reappraisals for R1 despite nine falls, multiple injuries, and hospitalizations, all of which constitute significant changes in condition. This posed an immediate health and safety risk to R1.

Residents in all residential care facilities for the elderly shall have all of the following personal rights:(16) To receive or reject medical care or other services. This requirement was not met as evidenced by. R1 did not receive timely medical evaluation or safe and healthful care after reporting a head injury. Staff failed to provide proper assessment and supervision. This posed an immediate health and safety risk to R1.

87412(f)All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure that staffing schedules for January, February and March of 2026 were readily available for the licensing agency to inspect. This posed a potential health safety and personal rights risk to 1 of 96 residents in care.

87202 Fire Clearance (a). All facilities shall maintain a fire clearance… Prior to … retaining any of the following types of persons, the… licensee shall notify the licensing agency and obtain an appropriate fire clearance… (2) Bedridden personsThis requirement was not met as evidenced by: Based on interview and record review, the licensee retained 1 Residents (R1-) without an approved fire clearance. This posed an immediate Health, Safety and personal rights risk to 1 of 96 Residents in care.

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staffThis requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure that two records for one resident (R1) were readily available for facility and licensing staff. This posed a potential health safety and personal rights risk to 1 of 96 residents in care.

87211 Reporting Requirements: “(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 94 residents (R1), Licensee did not furnish a written incident and death report to both the licensing agency and the residents’ responsible person within seven days of occurrence. This posed a potential health and personal rights risk to persons in care.

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: 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

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: 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.

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...A written report shall be submitted to the licensing agency and to the person responsible for the resident...Any serious injury as determined by the attending physician...This requirement was not met due to: R1 tested positive for COVID. Facility records show internal staff were notified, but RP was not informed of the diagnosis. CCL did not receive an incident report. Failure to notify RP of a significant change in condition violates reporting requirements and poses a health, safety and personal rights risk.

(a)Each resident shall have personal rights which include...(8) To have his/her... responsible persons... informed by the facility of activities related to his care or services...This requirement was not met as evidenced by: Based on interviews and records review the licensee did not inform R1's responsible person of the 30 day eviction which is related to R1's care. Failure to comply presented a substantial threat to the mental health and safety of R1.

Additional Personal Rights... (a)In addition to… 87468.1… residents… shall have… the following… rights: (4) to care, supervision… that meet their… needs and are delivered by staff… sufficient in numbers, qualifications, and competency… This requirement was not met as evidenced by Based on interview and record review, the Licensee did not ensure that R1 received care, supervision and services required by their medical condition, resulting in their fall, fracture, and contributing to their death. This posed an immediate Health, Safety, and Personal Rights risk to 1 of 99 persons in care.

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interview, the facility did not render housekeeping services to one resident (R1) as agreed. This posed a potential health, safety and personal rights risk to 1 of 99 residents in care.

To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse… this requirement was not met as evidenced by: Based on interview and records review, facility staff did not protect one resident (R2) from physical abuse by a resident with a known history of aggression (R1), which posed an immediate health, safety and personal rights risk to 2 of 99 residents in care.

...residents in ... residential care facilities for the elderly shall have all of the following personal rights:To care, supervision... that meet their individual needs and are delivered by staff that are sufficient in numbers... and competency to meet their needs. This requirement was not met as evidenced by: R1 who has mild cognitive impairment and is not permitted to leave the facility unsupervised, was able to leave the facility. R1 was located several hours later by an Officer in La Mesa. The facility did not ensure proper supervision, which posed an immediate health and safety risk to R1.

87466 Observation of the Resident The licensee shall ensure that residents are... observed for changes in physical, mental, emotional and social functioning and that... assistance is provided...This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not assist a resident with a history of aggression, resulting in a resident-on-resident altercation causing injury to 1 resident [R1], posing an immediate health, safety, and personal rights risk to 1 of 114 residents in care.

87211 Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case... This requirement was not met as evidence by: Based on records review, staff did not submit a written report to the Department within the allotted timeframes for 1 of 127 residents in care, which which posed a potential personal rights risk to 127 of 127 residents in care.

87466 Observation of the Resident The licensee shall ensure that residents are... observed for changes in physical, mental, emotional and social functioning and that... assistance is provided...This requirement was not met as evidenced by: Based on interview and record review, the licensee did not assist a resident with a history of aggression, resulting in a resident-on-resident altercation with injuries for 2 residents [R1 and R2], posing an immediate health, safety, and personal rights risk to 2 of 127 residents in care.

87303 Maintenance and Operation: "(a) The facility shall be clean...sanitary and in good repair at all times." This requirement was not met, as evidenced by: Based on manager interview and LPA observation, pertaining to the bedroom of 1 of 126 residents (R1), Licensee did not ensure that the facility was clean, sanitary, and in good repair at all times. This posed a potential personal rights risk to persons in care.

shall have signal systems which shall meet the following criteria: 1) All facilities licensed for 16 or more a....shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met in evidence as: Based on interviews and observations the licensee did not provide a working pendant for 2 of 120 persons in care which posed a potential Health, Safety, or Personal Rights risk to persons in care

In addition to Sections 87465(a) and 87464(d), the licensee shall ensure that the resident is cared for in accordance with the physicians orders and that the resident's medical needs are met. Based upon staff and outside agency interviews. The facility did not ensure that one out of 128 residents in care (R1) have their medical equipment transferred to their room. This posed a potential health risk to 1 of 1 of 128 persons in care.

1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 117 residents (R1), the licensee did not comply with its absentee notification plan. This posed a potential safety risk to persons in care.

Managed Incontinence - Licensee shall be responsible for ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Facility records show that residents often wake up with soiled diapers and linen.

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not met as evidenced by: Based on review of records and interviews, the licensee did not make arrangements to ensure transportation to medical appointments, which posed a potential health, safety, and personal rights risk to 130 of 130 in care.

Based on interview and record review the licensee did not comply with the section cited above in 6 of 6 persons which poses a potential and safety risk to 111 of 111 (R1-R111)

Based on observation and interview, the licensee did not comply with the section cited above in 1 of 1 identifiers which poses potential health and safety risk to persons in care.

Based on interview and record review the licensee did not comply with the section cited above in 6 of 6 persons which poses a potential and safety risk to 111 of 111 (R1-R111)

Based on observation, the licensee did not comply with the section cited above in 2 of 8 rooms inspected which posed a safety risk to persons in care.

Based on interview and record review the licensee did not comply with the section cited above in 6 of 6 persons which poses a potential and safety risk to 111 of 111 (R1-R111)

Based on observation, the licensee did not comply with the section cited above in 6 out of 8 bathrooms which poses a safety risk to persons in care.

Facilities shall have signal systems...All facilities licensed for 16 or more...shall have a signal system which shall:Operate from each resident's living unit.Transmit a visual and/or auditory signal to a central staffed location...loud enough to summon staff. This requirement was not met as evidenced by: Based on LPA direct observation the licensee did not have a functional signal system for R1 [1] of [1] of 109 persons in care which posed a potential health and safety risk to persons in care.

87555 General Food Service Requirements (b) The following food service requirements shall apply:(15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.This requirement was not met as evidenced by: Based on observations, interviews with staff, and records review, the licensee did not ensure employees engaged in food preparation were wearing the appropriate personal protective equipment to prevent food cross-contamination. This posed a potential health risk to 110 residents in care.

87411 Personnel Requirements – General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs.This requirement was not met as evidenced by: Based on interviews and observations, the licensee did not ensure the facility was adequately staffed to meet the needs of 110 residents. This posed a potential health and safety risk to 110 residents in care.

87465(C)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on observations, interviews, and records review, facility staff did not administer medications in accordance with the physician’s orders for R1, which posed a potential health risk to 1 of 110 persons in care.

87465 Incidental Medical and Dental Care: “(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.” This requirement was not met, as evidenced by: Based on records and interviews, during the incident, the licensee did not keep centrally stored medication in a safe and locked place not accessible to persons others than employees responsible for the supervision of centrally stored medication, which affected 1 of 109 residents (R1) and posed a potential safety risk to persons in care.

87468.2 Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs… this requirement was not met as evidence by: Based on interviews, records review, and observations, facility did not provide sufficient staff to meet resident’s care needs. This posed a potential personal rights risk to [R1] 1 of 97 residents in care.

H&SC 1569.652(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual… within 15 days after the personal property is removed.This requirement was not met as evidenced by: Based on interviews and records reviewed the licensee did not did not issue a refund within 15 days after personal property was removed for 1 in of 99 persons in care [R1] which posed a potential health and safety risk to persons in care.

87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by: Based on LPA observation, licensee did not have an auditory device or other staff alert feature on one exit door accessible to residents for whom exiting presents a hazard, which posed a potential safety risk to persons in care.

1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan…” This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not comply with its absentee notification plan for 1 of 97 residents (R1), which posed a potential safety risk to persons in care.