Bonita Villa Senior Living.

LPA Serrano arrived at the facility to deliver a case management investigation report related to a fall experienced by Resident 1 (R1) on 10/20/2025 and concerns regarding the facility’s response, medical assessment practices, supervision, and change in condition procedures. LPA met with Executive Director Abraham Botello and discussed the purpose of the visit. R1 moved into the independent living area on 10/28/2020 and did not require assistance with daily activities at the time of admission. On 10/20/2025, R1 contacted the front desk and requested help after they fell inside their room. Staff 1 (S1) responded and helped R1 up from the floor. S1 stated that R1 reported hitting their head during the fall. S1 reported that R1 appeared to have no visible injuries and reportedly refused medical care. Staff 2 and Staff 3 also responded to the call but did not enter the room or assess R1 for injuries. The Department interviewed the Administrator, who stated they believed R1 had no fall history prior to the 10/20/2025 incident. The Department reviewed R1’s facility records and identified a total of nine falls dating back to January 2024 . All but one occurred in R1’s room and were unwitnessed. Three of these falls resulted in hospital transport for serious injuries, including hip injuries. Records also indicated R1 hit their head in at least two prior falls. Additional documentation showed multiple hospital transports for breathing issues and other medical conditions. The only Physician’s Report available was dated 10/1/2020 , with no updated assessments on file. The Department conducted a follow-up interview with the Administrator. The Administrator stated they had only been in their role for a few months and were unaware of R1’s fall history. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The Department asked whether R1 had been re-evaluated given their repeated falls and clear changes in condition. The Administrator confirmed that no updated medical assessments existed. The Department advised the Administrator that based on the frequency of falls, injuries, and medical needs, R1 should have been considered for a higher level of care such as assisted living. The Administrator agreed. The Department’s review concluded that R1 had not been medically re-evaluated since 10/1/2020, despite multiple falls and significant medical concerns. The facility did not take steps to reduce R1’s fall risk or request a higher level of care. The Department reviewed the facility’s response to R1’s fall on 10/20/2025. S1 reported that R1 stated they hit their head. S2 and S3 responded but did not enter the room or assess R1. S1 1 claimed R1 refused medical treatment. S2 instructed S1 to monitor R1 every hour for any change in condition. The Administrator stated that while the facility has no written policy on suspected head injuries, staff are instructed to call 911 when a resident hits their head or is suspected of hitting their head. S3 confirmed this expectation. The Department interviewed R1. R1 stated they told S1 they hit their head hard and that their head and right side were hurting. R1 stated S1 did not assess them and that they did not refuse medical care. R1 stated they remained in their room for two days in pain until they contacted the front desk again. Facility records show that on 10/22/2025, S3 called 911 after R1 asked for help. The Department reviewed documentation and found no recorded hourly checks between 10/20/2025 and 10/22/2025, despite staff claiming these checks were performed. R1 also reported no staff checked on them during these dates. S3 confirmed that such monitoring should have been documented. Based on the information reviewed, the Department determined that the facility did not provide timely medical attention and did not conduct required monitoring after a reported head injury. The Department concluded that the facility failed to provide care and supervision, failed to observe and document changes in condition, and did not meet Title 22 RCFE requirements. Deficiencies were cited on LIC 809-D. An exit interview was conducted and a copy of this report along with the Licensee's Rights (LIC9058 03/22) was provided to Abraham Botello signature on this form confirms receipt of these documents.

On 4/14/2026 LPA Ramon Serrano arrived to the facility to conduct a case-management deficiencies visit. LPA was greeted by Executive Director Abraham Botello and LPA explained the purpose of the visit. On 4/6/2026, the Department conducted a case management visit to follow up on the self-reported death of a Resident (R1) [see 811 confidential names list]. During the visit, records were requested, however, three of the requested records could not be provided to the Department as required. An interview was conducted with the Executive Director (ED) who clarified that three records were not available due to the Resident Services Director (RSD) being out of the facility. The records included R1’s Preplacement Appraisal, LIC602 Physician’s Reports, as well as Caregiver Work Schedules for the months of January, February, and March. On 4/14/2026 the department conducted a review of records that were obtained and identified that R1 was bedridden (R1). Interview conducted with ADM who believed R1 was bedbound. R1’s Needs and Service Plan update for Grooming dated 2/20/2026 was reviewed and indicated “Resident is Bed Bound.” A review of the facility narrative charting notes that on 9/3/2025, it was documented that R1 required repositioning every two hours to prevent bed sores. A review of the facility file was conducted on 4/14/2026 which revealed that the facility was licensed for 145 non-ambulatory residents, and 0 bedridden residents. During today’s visit, a health and safety visit was conducted which revealed that there were four (4) bedridden residents present. Three (3) citations were issued and can be found on the attached LIC 809(D). Per California Health and Safety Code §1569.49 (c)(2)(A), a $500 immediate civil penalty was also assessed for a violation of the facility’s fire clearance [see attached LIC 421-IM]. An exit interview was conducted with Executive Director Abraham Botello, to whom a copy of this report, the LIC809-D page, the LIC421-IM page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Abraham Botello. Today's visit was in response to an LIC624 Incident Report and an LIC624A Death Report regarding Resident #1 (R1), which Licensee self-submitted to the CCLD San Diego Regional Office (RO); both reports were received on 04/03/2026. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. According to these reports: R1 fell at the facility on 03/25/2026, for which they were hospitalized. Then on 03/26/2026, R1 died at the hospital. During today’s visit, LPA performed a brief facility tour and welfare check on remaining clients, finding no immediate safety concerns. LPA collected and/or requested copies of and reviewed pertinent records and interviewed relevant staff. LPA also provided Technical Assistance (TA) / education to Botello regarding CCLD’s Provider Information Notice (PIN) 26-06-ASC, titled, “Calling 9-1-1 in Residential Care Facilities for the Elderly (RCFE).” A physical copy of the PIN was provided to Botello, and an electronic copy of the same was E-mailed to both him and the facility’s Resident Services Director, Richard Tibi. [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] The above LIC624 and LIC624A reports were both received at the RO late, meaning not within seven (7) days of either R1’s fall or R1’s subsequent death, respectively, as required by regulation. One (1) deficiency was cited today per California Code of Regulations, Title 22 (refer to the attached LIC809-D page). Since this deficiency was a repeat violation within a twelve (1 2) month period, a Repeat Violation Civil Penalty of $250 was assessed/charged (refer to the LIC421-FC page). An exit interview was conducted with Executive Director Abraham Botello, to whom a copy of this report, the LIC809-D page, the LIC421-FC page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.

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.

OS explained that medtechs were calling the wrong number and leaving messages. OS later learned that the medtechs had the correct number but were transposing digits when making calls. OS stated that in the past few months, everything has been fine with the facility and R1. LPA interviewed R1, who stated that facility staff are in regular contact with RP. R1 confirmed that they had COVID some time ago and were sent to the hospital. R1 stated that staff advised RP about the COVID diagnosis. LPA interviewed the Resident Services Director (RSD), who stated that this incident occurred before they were hired. RSD explained that the medtech responsible for communication at the time was terminated and no longer works at the facility. RSD believed RP was informed of R1’s COVID diagnosis. RSD stated that an incident report was never generated or submitted to CCL. LPA interviewed Staff 1 (S1), who stated that they never spoke directly with RP but left a voicemail requesting more disposable undergarments for R1. S1 recalled RP later saying they were never told about R1 having COVID when they came to visit. LPA reviewed R1’s records and noted that R1 has a primary diagnosis of bladder cancer, is listed as having dementia, and their physical health status is documented as poor. Chart notes from March 2025 through October 2025 were reviewed. On August 1, 2025, notes show that R1 tested positive for COVID and that RSD and the Memory Care Director were notified. Later that same day, S1 documented that they informed RP about the need for more disposable undergarments. However, there is no clear documentation showing that RP was informed of R1’s COVID diagnosis. Based on interviews and record review, there is evidence that R1 tested positive for COVID and was hospitalized. RP indicated they were not properly notified and facility staff confirmed that they never spoke directly to RP. An incident report was never submitted to CCL. There is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be 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 Business Office Manager Raymie Cruz A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Raymie Cruz at the conclusion of the visit. The signature below confirms the receipt of these documents.

OS also stated that R1 has dementia and never told RP or other family members about the eviction. LPA reviewed facility records and found that on October 13, 2025, CCL received a copy of a 30-day notice to quit for R1. The notice stated that R1’s residency would end on November 13, 2025, because R1 was not following the facility’s general policies. LPA reviewed R1’s chart notes from October 15, 2024, through July 21, 2025. The notes showed several incidents where R1 was aggressive toward other residents and staff. On October 15, 2024, R1 chased another resident and harassed them because they were reading outside their room. On November 23, 2024, R1 yelled at staff about dinner and chased them. On June 13, 2025, R1 threatened to slap another resident for humming. LPA also reviewed emails between facility management. On September 10, 2025, the facility’s legal team advised management to give R1 an official eviction notice. On October 13, 2025, the Resident Services Director (RSD) emailed that they spoke with RP, who said they were having trouble finding a new placement for R1 but were still actively searching. LPA interviewed RSD, who said they and corporate staff told RP in August and September 2025 that R1 needed to move because of aggression toward other residents. RP said they were looking for a new place. RSD stated they told RP by phone on October 13, 2025, that R1 was being given a 30-day notice. LPA also interviewed outside source 2 (OS2), who said they learned about the eviction on January 22, 2026, when the facility told them R1 needed to be picked up or law enforcement would remove them. OS2 said they knew R1 had issues but never received a 30-day notice by mail or phone. LPA reviewed records and found the facility mailed the 30-day notice to RP by certified mail, but the mail was returned on November 10, 2025, because it could not be delivered. LPA interviewed the Executive Director (ED), who said R1 was officially evicted on January 22, 2026. ED said the notice was sent by certified mail and a court order was posted on R1’s door. ED stated that R1’s family visited during the holidays and would have seen the posted notice. ED stated that although law enforcement arrived at the facility on 1/22/26, they stated that since it was a "civil" matter they could not arrest or transport R1. ED under the advice of law enforcement transported R1 to the hospital and advised hospital staff of the situation. Based on the investigation, LPA determined that the facility had the right to evict R1 because of repeated aggression toward other residents. However, the facility failed to properly inform RP about the eviction. The 30-day notice included important information and resources that RP never received. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during interviews and records review, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be 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 Abraham Botello. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), and immediate Civil Penalties were assessed and provided to Abraham Botello at the conclusion of the visit. The signature below confirms the receipt of these documents.

ED stated by December 21, 2023, R1 was re-assessed for assisted living which indicated that R1 required more assistance with daily tasks.  ED said the caregivers were reporting that R1 was having difficulty keeping their room clutter free and organized. ED stated R1 had a cat and R1 was unable to keep the cat box clean, and the cats water dish was constantly spilling onto the floor causing a fall risk for R1. ED stated housekeeping was cleaning after the cat and making sure the water dish was not spilled on the floor and cleaning R1’s room because their floors were cluttered and they were worried about R1 falling. ED stated by early March 2024, ED and R1’s family decided to schedule daily housekeeping for R1 since they were unable to keep their room clean, mostly due from mild dementia that was progressive and they continued to decline. It was also revealed that R1’s Designated housekeeper (S1) resigned on May 2, 2024 and no additional housekeeping was assigned to R1. ED stated that they were looking to hire extra staff but at that time no one was cleaning R1’s room up  for approximately 19 days leading to R1’s fall, which resulted in a hip fracture. ED stated they were unaware of R1 having any history of falls. ED also said that they were unaware that R1 was on a waiting list for memory care and that they did not follow-up on that. ED said that they were planning to look into what was going on with R, but they had not been able to get to it before R1’s fall, on May 22, 2024. The Department interviewed Resident Care Coordinator, RCC, Stephanie Iffland. RCC said former Residential Service Director (FRSD) Jennifer Brown was working with the family about R1 but abruptly separated from the facility without notes or information regarding the residents. The Department asked RCC with the changes and concerns with R1, why wasn’t R1 re-evaluated, and RCC was unable to answer. RCC admitted that R1 had sustained at least nine (9) falls that they were aware of and felt R1 needed more assistance with their care. RCC also said that housekeeping was being provided daily for R1 but it was not enough because R1 would take everything back out and leave clothes, food, wrappers, and shoes on their bedroom floor. RCC stated the Caregivers also reported that they witnessed R1 eating cat food and urinating in the litter box. RCC said that R1 had a weak knee, many falls and was encouraged to use their pendant for assistance. However, R1 rarely used their pendant and did not ask for assistance. The Department asked RCC if R1 should have been moved to memory care or re-evaluated for possibly a higher level of care. RCC said yes, R1 should have been re-evaluated.  The Department asked why didn’t they schedule another housekeeper to clean R1’s room when the last one quit. RCC said they didn’t know what was going on regarding hiring additional housekeepers and that they were not sure why no one reported the condition of R1’s room. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The Department interviewed staff (S1). S1 stated R1 kept taking items out and would tell everyone that they needed to organize their room, but left it a mess. S1 said they would offer to help R1 but they would get upset and irritated and refused any help. S1 also stated during the time of the former RSD, a caregiver reported to them that R1 was eating cat food and staff took it away from them. R1 told caregiver that it was okay to eat cat food, and caregiver suspected that R1 was showing signs of dementia or urinary tract infection, but they were also always confused and did not know where they were most of the time. S1 further stated R1 continued to display forgetfulness and at times was unable to find their room and would be found crying in the hallway until a caregiver found them. S1 said R1 had also bad knees, and often complained of pain and had shortness of breath. S1 said they and other MedTech’s notified former FRSD Jennifer Brown about the changes and concerns R1 was displaying by December 2023. S1 said the family agreed to provide daily housekeeping for R1 but there were days that R1 would not allow housekeeping to come in and clean the room. S1 stated FRSD Brown had mentioned that it appeared that R1 displayed signs of dementia, sundowning and was on the waitlist for memory care and staff was conducting status checks throughout the shift and after meals. The Department interviewed Resident Services Director (RSD), Mitchell Shayla Shajun. RSD stated they started working six weeks prior and was picking up where former RSD Jennifer Brown left off. RSD said that Brown did not stay long enough to go over any resident updates or managerial task that needed to be addressed.  RSD stated they were recently made aware of R1’s behavior, and staff shared their concerns regarding R1 eating cat food and going to the bathroom everywhere. RSD stated Staff did not bring up these concerns regarding R1 refusing to shower, or having their briefs changed because R1 had a history of UTI’s (urinary tract infections). RSD said they knew about R1’s mobility issues because they were having a lot of falls. RSD admitted to not following up with family because it was until R1’s fall that these concerns were brought to her attention, and that they knew about the last two falls. RSD believed that R1’s change of condition was discussed with family and they had agreed to placing R1 in memory care. However, RSD clarified that they did not follow-up or look into the matter because they were still in training and learning their position. On August 15, 2024, the Department interviewed staff 2 (S2). S2 stated R1’s room was always a mess and malodorous due to the cat box and human and animal feces throughout the studio. S2 also stated caregivers were conducting frequent checks every hour or two to make sure R1 was okay. S2 stated R1 was anxious, depressed and displaying great confusion. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 S2 stated R1 was unable to care for themself or their cat. S2 said the staff hid the cat food because R1 would eat it and they told the family not to bring cleaning supplies to R1 because they were worried R1 might do something unsafe with them. S2 also explained that staff had requested to turn off the water to R1’s kitchen sink because they would get water all over the floor and was likely to fall. S2 said R1 had a bad knee, weak legs and a cluttered studio no matter how often housekeeping came to clean. S2 believed that all of this contributed to all of R1’s falls, which occurred in their room. On September 16, 2024, the Department interviewed staff 3 (S3). S3 stated they cleaned R1’s room daily, and sometimes three to four times in one day because R1 had a compulsive disorder to move and “organize” their room resulting in unsafe environment. S3 believed R1 needed to be re-assessed and placed in a higher level of care, as they were very confused. Despite R1’s worsening Dementia, R1’s family and facility management were not making any changes or placing them in memory care. S3 also corroborated that R1 had a bad knee, weak legs, and consumed cat food and feces; but no one addressed these concerns. S3 stated R1 refused to shower when they were covered in feces and also did not like changing their briefs when they were soiled. S3 believed that Management should have re-assessed R1. On September 27, 2024, the Department interviewed R1’s Family Member, FM. FM said that they had some concerns about the facility because they believed that they were understaffed and unable to provide the care and services that R1 required. FM stated R1 had been diagnosed with Alzheimer’s seven years prior and that they were moved from a sister facility because they could no longer provide the level of care R1 required. FM stated when they moved R1 into the facility, former Residential Service Director Jennifer Brown said they would be able to accommodate R1. FM stated they checked on R1 once a week and reported R1’s room was dirty and cluttered. FM agreed to pay for daily housekeeping, which went well until the housekeeper left, and the facility was unable to hire additional staff to clean R1’s room. FM believed the facility may have forgotten about the agreement when the new Residential Service Director was hired. The Department reviewed facility records which included R1’s appraisal and care notes from November 18, 2023- May 29, 2024. According to the record, R1 moved in the facility on 11/17/23 and had 10 falls through 05/22/24. One note dated 5/22/2024 stated R1 had sustained a fall and R1 expressed they were in pain. When staff tried to touch R1’s hip, R1 shrieked. They were a bit shaky, and taken to the hospital. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 R1’s initial appraisal, completed by former Residential Service Director (RSD) Jennifer Brown, noted that R1 required very limited assistance and was noted to be independent. There was no indication of R1 having Dementia or Alzheimer’s, despite their pre-placement appraisal dated 11/16/23 noting that they had dementia, depression and anxiety. Within a few months R1’s behavior had dramatically changed and staff was reporting that R1 was requiring more assistance and more status checks. Even though R1 was issued a pendant for assistance, R1 rarely used it to call for assistance. The staff conducted two-hour status checks on R1 and housekeeping had been upgraded to daily with no additional cost due to the habitual clutter and trash in R1’s room. The staff had notified the family members as to the daily clutter that R1 had in their room and it became difficult to keep their room clean and cluttered free causing a safety risk. Staff reported that R1’s confusion increased and had found R1 eating cat food from the can. During De

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit.  LPA was greeted by and met with Resident Services Director Richard Tibi, to discuss the purpose of the visit. Today's visit is in response to the self reported incident involving Resident 1 (R1- see LIC811 Confidential Names List) who eloped from the facility and was found later that same day in La Mesa. An Incident report was submitted to CCLD reporting the following: On 10/03/2025 at approximately 9:30 AM , staff conducted a routine check and discovered that Resident 1 (R1) was not in their room. Staff immediately began searching inside and outside the facility. During the search, a staff member who was on break informed the Executive Director (ED) that they saw R1 a few blocks away from the facility. After about one hour of unsuccessful searching, staff notified R1’s Power of Attorney (POA) and contacted the Sheriff’s Department to report the incident. The Sheriff’s Department initiated a search; however, R1 was not located at that time. At approximately 7:50 PM , a staff member received a call from a Transit Security Officer stating that they had R1 at the trolley station in La Mesa on Spring Street and La Mesa Boulevard. The officer reported that R1 was very intoxicated and had shown them the facility’s business card, stating, “That is where I live.” After receiving this information, staff contacted the ED, who immediately went to pick up R1. R1 returned to the facility around 9:00 PM . The POA was notified, and R1’s primary care physician was also informed. On 12/22/2025, LPA interviewed R1 in the facility’s patio area. R1 was well-groomed and appropriately dressed. R1 stated that prior to the incident, they believed they had a stroke and had gone to the hospital several times to get checked. On the day of the incident, R1 said they intended to visit their spouse and child’s graves at Glen Abbey Cemetery. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 After visiting, they took a bus and ended up at Fashion Valley Mall. R1 then boarded a trolley, thinking it would take them back to Chula Vista, but they ended up in La Mesa. R1 stated that they told an officer they were lost and showed the officer the facility’s business card. The officer then contacted the facility, and the ED picked R1 up. R1 believes they may have had a stroke that caused confusion that day and stated they were checked out and are doing well now. LPA reviewed R1’s records. According to the physician’s report dated 08/05/2025 , R1 has mild cognitive impairment, hypertension, and a history of alcohol use disorder. R1 is not permitted to leave the facility unsupervised and is disoriented to time and date. LPA interviewed Executive Director (ED) who stated that on the date of the incident R1 eloped during lunch service. ED stated that R1 usually sits near the front door of the facility and believes that due to lack of supervision R1 was able to exit the building and walk away from the facility. Based on the information obtained, the facility did not ensure that R1 remained under supervision as required. This poses a potential health and safety risk to residents in care.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 Resident Services Director Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), was provided to Richard Tibi at the conclusion of the visit. The signature below confirms the receipt of these documents.

R1’s physician’s report (LIC602) dated November 9, 2022, indicated that R1 is ambulatory and has an underlying medical condition that is described as a progressive brain disorder leading to memory loss, confusion, language problems, and personality changes, per Google AI overview. The report further stated that R1 required full supervision and assistance with activities of daily living. Their underlying medical condition was described as permanent and severe. R2’s LIC602 further describes their mental condition as confused, disoriented, exhibiting inappropriate behaviors, intermittent aggression, wandering, and sundowning. R1’s preplacement appraisal dated November 28, 2023, noted episodes of confusion and the need for R2 to have special observation and night supervision due to wandering. R2’s LIC602 was also reviewed. R2 was non-ambulatory and is a fall risk. They have an underlying condition that, per AI overview, is described as a condition where cells, tissues, or organs progressively break down and lose function over time, which affects their nervous system. They are also diagnosed with a condition that affects their memory. Their LIC602 further shows that R2 is able to follow instructions, communicate their needs, and store their own medications. Resident interviews were conducted. An interview with R1 was attempted but was unsuccessful due to limited verbal skills; R1 only smiled and did not verbally respond. R2 was interviewed and corroborated the incident, stating that R1 entered their room, ignored verbal redirection, slapped them with an open hand, and knocked their glasses off their face. Staff responded to the incident and contacted law enforcement. Staff interviews were conducted. Staff member S1 corroborated the incident, explaining they had left R2’s room briefly to assist another resident. Upon their return, they found R2 crying and were informed that R1 had entered the room and slapped them. S1 observed R2’s glasses knocked off. S1 reported that R1 has exhibited escalating aggressive behaviors, including attempts to hit caregivers and urinating in random areas. Former Executive Director Rebecca Toves arranged for a one to one caregiver contracted by the VA to assist R1 three times per week following the incident. Interviews with outside sources were also conducted. One outside source stated that staffing at the facility was adequate but limited, remarking that “they can only do so much.” Another outside source confirmed that R1 received VA assistance after the incident. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Law enforcement corroborated that they had responded to the facility on multiple occasions for incidents involving R1, including altercations with other residents resulting in minor injuries. R1 was described as frequently getting into altercations and sometimes becoming violent. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff, resident, and outside source interviews, and records review, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D. The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with RSD Richard Tibi, to whom a copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.

LPA reviewed R1's charting notes dated October 15, 2024 through July 21, 2025. On October 15, 2024 R1 "chased" another resident to the lobby area and harassed them due to the resident reading outside of their room, which R1 did not like. On November 23, 2024 R1 was verbally abusive towards staff regarding R1's dinner. R1 chased after staff and yelled at them. On June 13, 2025 R1 became very aggressive with another resident due the other resident "humming." R1 told the resident that R1 would "slap" them in the face if they continued to hum. LPA Interviewed R1 who stated that they have lived at the facility less then a year. R1 stated that although they only have a few friends at the facility, they do know every resident by their face. R1 stated that just prior to speaking with LPA they accidentally sat down next to a resident that they previously had a minor disagreement with. R1 explained that they asked the other resident if they were the one they had a disagreement with earlier in the day. R1 stated that the resident said "yes" and they both laughed. R1 denied having any altercations, disagreements or aggression towards other residents in the past. R1 stated that if they are ever annoyed with another resident they just ignore them and forget about it. LPA interviewed R2 who stated that on the date of the incident they recall arguing with R1. R2 stated that they could not remember what they were arguing about. R2 stated that R1 came up to them and "twisted their arm off" R2 stated that after R1 hit them, R1 had an angry look in their eyes that frightened R2 and R2 thought they were going to come back after them, but they didn't. R2 stated "I just think that R1 is an angry, angry person. R2 stated that R1 has a history of being aggressive and angry with other residents, R2 stated that an incident occurred in the past where R1 became aggressive with another resident but R2 could not recall what exactly happened and who the resident was since it occurred a while back. LPA interviewed Resident 3 (R3) who stated that they witnessed the incident that occurred on July 21, 2025. R3 stated that R1 was talking to them in the lobby area when R1 stopped turned to R2 and stated " we are having a private conversation, I'm talking to my friend." R2 said something and R1 yelled "what did you say?" R3 stated that R1 began to "tussle" with R2. R3 stated that the facility staff then came and separated R1 and R2. R3 stated that R1 has been aggressive with other residents in the past. R3 stated that R1 argued with another resident because they were whistling and it upset R1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA interviewed Staff 1 (S1) who stated that they were informed that on the date of the incident R1 became aggressive towards R2. S1 stated that R1 grabbed R2's arm resulting in a arm injury. S1 stated that after the incident R1's family promised that they would provide R1 with a private caregiver. S1 stated that R1's private caregiver was only seen for two to three days and they never returned. S1 stated that after a recent incident of elopement they spoke with R1's responsible party informing them that R1 needed a higher level of care. S1 stated that R1's responsible party is in the process of finding new placement for R1. LPA reviewed a San Diego Sheriff's incident report (SDSIR) dated July 21, 2025. SDSIR indicated that R1 initiated a physical altercation with their neighbor R2 at their shared elderly care facility. SDSIR stated that R1 grabbed R2's forearms, resulting in a severe laceration to R2's right forearm. R2 was transported to a local hospital for medical treatment. Both residents were described as having mental cognitive deterioration. Staff members at the facility described R1 as having cognitive deterioration. Based on the statements collected, the injury to R2's arm, and the totality of the circumstances, R1 was placed on a 5150-hold pending psychiatric evaluation. Had R1 been left at the residential facility, it is believed that R1 would have likely continued being a danger to other residents and staff members. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during interviews and records review, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be 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 Resident Services Director Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), and immediate Civil Penalties were assessed and provided to Richard Tibi at the conclusion of the visit. The signature below confirms the receipt of these documents.

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced visit to deliver investigative findings and in conjunction, conducted this case management visit. LPA identified herself and was granted entry by Annmarie Salazar, Resident Service Coordinator. LPA stated the purpose of the visit and reviewed the basic elements of this visit with Executive Director Abraham Botello. During the Department’s investigation of complaint control # 08-AS-20250403173506, there were additional discrepancies found, which are being addressed during today’s visit. During the investigation, which consisted of interviews with staff and residents, and records review of relevant documents, the investigation uncovered that the facility documents for residents needed to be updated. During today’s visit, LPA spoke with the Executive Director Botello and reviewed the following California Code of Regulations: 87208 Plan of Operations, 87458 Medical Assessment, 87101 Definitions, and 87463 Reappraisals. LPA also provided the Executive Director with the Department’s flyer for Important Updates to Dementia Care and Miscellaneous Changes , which took effect January 1, 2025. The flyer had a QR code that directs the recipient to the Department’s website and informs the viewers of updated regulations that impact RCFE facilities. Additionally, the facility did not report the incident that transpired on April 1, 2025, until LPA opened the investigation on April 10, 2025. Based on the information obtained during the investigation, an additional deficiency was observed and cited, and technical advisories were provided which may be reviewed on the LIC809-D and LIC9102TA pages of this report. The report was discussed, and an exit interview was conducted with Executive Director Abraham Botello. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Botello at the conclusion of the visit. The signature below confirms the receipt of these documents.

(Continuation of LIC9099) When S1 went to see what the commotion was regarding, S1 found both R1 and R2 were face-to-face, confronting each other. S1 separated both R1 and R2, and they were directed to their rooms. S1 spoke with R1, who said R2 had hit them with a decorative figurine, which has since been removed. According to S1, they were informed that the incident had started earlier in the day, between R1 and Resident #3 (R3) during an activity. The facility had an activity that included the consumption of wine. According to S1, R1 usually attends this activity with friends, who bring their own alcohol. It had come to S1’s attention that R3 had made a comment to R1 regarding their heritage. According to an interview with R2, they said they had seen R1 argue with another unknown resident at the dining table, prior to leaving the dining area. After they left the dining area, they went to the elevator, and R1 called them an “asshole” and a “motherfucker.” R1 went towards them, with their motorized scooter, and ran into them while at the elevator. R2 then confirmed they retrieved a decorative ceramic figurine and hit R1 in the chin. R1 commenced to yell at them and then took the ceramic figurine with them so they can inform everyone what R2 had hit them with. R2 said that staff #3 (S3) came out of the employee’s lounge, and R2 informed them of the incident. Later, law enforcement came by to obtain statements, and since they defended themselves, they were not in trouble. According to Resident #3 (R3), they had seen R2 pouting in the dining area. When they asked what was wrong, they informed them that they had an incident with R1. Minutes later, R3 then accompanied R2 to their room, where law enforcement was waiting for them to obtain a statement. During this time, R1 passed by their room and did this approximately 3 times to intimidate them, but they were there to protect R2. Interviews were conducted with resident #4 (R4), who said they heard commotion but did not recall details. A review of records revealed that, since 2023, the resident has had numerous documented altercations, inebriations, and acts of aggression toward other residents. Photos revealed the residents’ bruising. R2 had bruising to the inner thigh of their right leg. R1 had bruising to the bottom left side of their chin. The facility provided the resident and the RP with a violation notice of the rules, dated April 3, 2025. While a care conference had been scheduled with R1’s responsible party after the alleged incident, there were no documented attempts by the facility to address R1’s known aggression and/or behavioral expressions over the prior 2 years. LPA reviewed R1’s file again on August 8, 2025, and there were no updated information as to the updates to R1’s care plan. The Department requested law enforcement reports but there were no responsive records for this incident. (Continuation on LIC9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continuation of LIC9099-C) Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be 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 Abraham Botello, Executive Director. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), and immediate Civil Penalties were assessed and provided to Executive Director Botello at the conclusion of the visit. The signature below confirms the receipt of these documents. This is an amended version to an original report delivered on 08/08/2025.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Collateral Visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Rebecca Toves. During today’s visit, LPA conducted staff and residents interviews to aid in an investigation involving a different licensed care facility. During LPA's time at Bonita Villa Senior Living, he observed that the carpet inside Apartment #211, belonging to Resident #1 (R1), was significantly stained/dirty. [See LIC811 Confidential Names List for a description of R1.] Interviews of manager and outside sources aligned to show: The carpet in this apartment is almost five (5) years old. Licensee had earlier constructive knowledge of the staining, and acknowledged the need to remedy it. Licensee had not yet remedied it. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Toves, to whom a copy of this report, the LIC 809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Based on observations and interviews, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Rebecca Toves , to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA Strong reviewed an invoice for the weekend of October 19, 2024, dated October 21, 2024, with charges for parts, labor, and emergency visit. LPA Strong called the facility phone number on October 22, 2024, and October 30, 2024, and the telephone was answered promptly by receptionist. It was also alleged that housekeeping staff assigned to R1’s room were not providing complete room cleaning from regular bathroom maintenance to vacuuming. Interview with staff assigned to R1’s room revealed that they provided extra cleaning care and attention to R1 as R1 had requested more assistance. Records reviewed shows facility room cleaning checklist which includes floor care and general cleaning of bathrooms. Interview with an outside source revealed that staff provide regular room care as noted in residents’ rooms. LPA observed R1’s room on October 30, 2024, which was clean and organized. Lastly it was alleged R1 did not receive assistance with bathing. Records collected revealed staff notes that showed R1 has verbally declined regular scheduled bathing and requested it to be pushed out. Interview with R1 did not reveal any information to corroborate that R1 did not receive bathing assistance. Interview with other resident did not reveal any information to corroborate that residents are not receiving assistance with bathing. Interview with outside source did not reveal other residents do not receive assistance with their scheduled bathing. Based on multiple interviews and record reviews, there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Rebecca Toves to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

LPA asked R1 if the facility staff remind them to put it back on. R1 exclaimed "oh yeah, they remind me all the time." R1 stated that they did not have their oxygen tank when they moved to their temporary room. R1 stated that they could not remember how many days they did not have their oxygen. R1 further stated that the staff probably forgot about it, since R1 never mentioned it to them. LPA interviewed outside agency (OA) who stated that R1 arrived at the emergency room with a low oxygen saturation. OA stated that R1 is required to be on oxygen 24/7.OA stated that the facility was treating R1's room for bed bugs and as a result, R1 was transferred to a different room. OA further stated that staff member 1 (S1) advised OA that R1 was moved to their temporary room without their oxygen tank. S1 further stated that since the room was being treated, staff could not enter the room to retrieve it. OA believes R1 was without their oxygen tank for several days. LPA interviewed R1's responsible party (RP) who stated that R1 has lived at the facility approximately four years. RP stated that R1 is a "pain" and stubborn. RP stated that R1 regularly goes against doctor's orders and refuses to wear compression socks and removes their oxygen regularly. RP stated that R1 will throw staff out of R1's room although they are just trying to help. LPA interviewed S1 who stated that they "do not know what happened" in regards to R1's oxygen tank. S1 stated that R1's oxygen tank was not with R1 prior to being transported to the hospital. S1 explained that R1's room was being treated for bed bugs and facility staff forgot to move R1's oxygen tank to their temporary room. S1 believes that R1 did not have their oxygen on at the time of the move which caused staff to leave the tank in the room. S1 stated that since the room was being treated for bed bugs staff could not enter the room to retrieve the oxygen tank. S1 estimated that R1 was without their oxygen tank for approximately two days. LPA interviewed staff member 2 (S2) who stated that they assisted in clearing out R1's temporary room. S2 stated that they noticed that R1's oxygen tank was not transferred to the room. S2 stated that R1 was without their oxygen for approximately two days. S2 stated that they believe staff simply "forgot to move it out." 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA interviewed Executive Director (ED) who stated that she was not aware of the incident involving R1 and their oxygen tank until today. ED stated that she was out of the office during that time frame and was not advised by staff of the incident. ED further stated that facility staff should be aware of R1's need for oxygen since R1 has an "oxygen sign" posted outside of their door. Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An exit interview was conducted with Rebecca Toves and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Rebecca Toves whose signature below confirms receipt of documents.

Additional interviews revealed the facility may, or may not cover the Uber bill, and some medical appointments were missed due to the lack of transportation service at the facility. A review of the facility’s website and admission agreement corroborated the facility had advertised transportation and agreed to provide such service. An interview with the facility’s Executive Director confirmed the facility was responsible for scheduling and providing transportation to medical appointments. Based on evidence obtained, the preponderance of evidence standard was met, therefore, the allegation was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Memory Care Director Jeralyn Markiewicz. An exit interview was conducted with Markiewicz, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058) were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the evidence obtained at the facility, there was not a preponderance of evidence to prove the alleged violation occurred. The allegation was unsubstantiated. An exit interview was conducted with Markiewicz, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility Executive Director Rebecca Toves, after identifying herself and stating the purpose of the inspection. This facility serves one hundred fourty five, residents 60 and above. Hospice waiver approved for fifteen. A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There is a water features in the courtyard made inaccessible to residents. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Overhead as well bedside lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in each building. Emergency lighting, and facility telephone were all working. First aid kit(s) were complete and readily accessible in the medical rooms. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Indoor passageways were free from obstructions. Food supply is replenished frequently by outside vendors. Food was observed to be properly labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts. Medications were labeled and kept in compliance with label instructions. [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a review of In-service training procedures. LPA interviewed Executive Director Toves as well as staff and was assured transportation procedures as well as outside medical and dental assistance procedure are compliant. There are two large common rooms used for dining and activities. At the time of visit, LPA observed a few residents participating in a small group activity. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. Staff records review verified that all staff records were not complete and compliant. During today’s visit, LPA file review and staff interview, for 6 of 6 care staff (S1-S6) licensee did not have the required First Aid and/or Cardio Pulmonary Resuscitation (CPR) certificates , which posed a potential safety risk to persons in care. Facility has a two-day supply of perishable food and did not have a seven-day supply of nonperishable food items. Some food supplies were kept in in an locked storage area. During today’s visit, LPA observed storeroom with very limited food supplies. Therefore, did not meet the required one week of nonperishable ‘supplies, which posed a potential health and safety risk to persons in care. During today’s visit LPA toured residents’ rooms and observed some showers did not have non-skid mats or non-skid strips. This poses a safety risk to persons in care. An exit interview was conducted with Executive Director Tover to whom copies of this report, Licensee/Appeal Rights (LIC9058 03/22), and 809-D’s were provided at the conclusion of the visit.

Facility staff was unable to retrieve the pendant information via computer so facility staff asked a caregiver to press R1's pendant button so we could hear it over the speaker. Several minutes passed and facility staff advised LPA that R1's pendent button was not working. Facility staff replaced R1's pendant button and LPA was able to hear via radio/speaker that R1's pendant button was functional and working. Facility staff advised LPA that the call button system in the facility was old and has issues at times. Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An exit interview was conducted with Rebecca Toves and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Rebecca Toves whose signature below confirms receipt of documents.