Complaint Investigation Report

374603431-2-24-2026-08-AS-SMOA-DRSSET-20260302124915

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN DIEGO RO , 7575 METROPOLITAN DR. #109

This is an official report of an unannounced visit/investigation of a complaint received in our office on

03/22/2022 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 08-AS-20220322083246

Executive Director Bonghabih, Shey, Smith, and Facility Gereontoligist/ Family Counselor Sophia Anguiano

Neglect to resident resulting in unexplained serious injury

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with Executive Director Bonghabih, Shey, Smith, and Facility Gereontoligist/ Family Counselor Sophia Anguiano, and explained the purpose of today’s visit.

Regarding the allegation Neglect to resident resulting in unexplained serious injury. Resident 1 sustained an unexplained serious injury while in care. The Department reviewed facility records, medical documentation, and conducted multiple staff and resident interviews. Records reflect that on 03/02/2022, Resident 1 was being assisted by a caregiver during a transfer from bed to wheelchair when she sustained a laceration to her left leg. Medical records confirm the injury required 16 staples for closure at Sharp Chula Vista Hospital. The investigation revealed that the facility-provided wheelchair had an exposed sharp metal rod protruding from the torn seat, which likely caused the laceration during the transfer. It was also determined that although Resident 1 had previously been identified as requiring two-person assistance with transfers due to weakness and edema, on the morning of the incident only one caregiver assisted her. Based on records reviewed and interviews conducted, there is sufficient evidence to determine that the facility staff failed to provide adequate care and supervision and failed to ensure that equipment provided to Resident 1 was safe for use. This resulted in a serious injury requiring medical attention. The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted with facility staff Executive Director Bonghabih, Shey, Smith, and Facility Gereontoligist/ Family Counselor Sophia Anguiano, and appeal rights provided.