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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600890
Report Date: 09/11/2020
Date Signed: 09/11/2020 02:47:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ATRIA COLLWOODFACILITY NUMBER:
374600890
ADMINISTRATOR:KRXZYSZTOF WALUSZKOFACILITY TYPE:
740
ADDRESS:5308 MONROE AVETELEPHONE:
(619) 286-3583
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:185CENSUS: 86DATE:
09/11/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Resident Services Coordinator, Evana MilanoTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA), Debbie Correia, contacted the facility via telephone to conduct a Case Management Visit. The visit is being conducted virtually via FaceTime due to COVID-19. LPA identified herself and explained the purpose of the call to Resident Services Coordinator, Evana Milano

The visit was in response to a Special Incident Report CCL received on 08/31/2020 regarding facility staff discovering Resident 1 (R1) has a stage 3 wound after reviewing notes left by R1's Home Health agency. R1 is receiving wound care through Kaiser Home Health. During today's visit, LPA conducted a virtual health and safety check. LPA requested R1's facility and Home Health records for further analysis. No deficiencies were cited during the visit.

An exit interview was conducted with Resident Services Coordinator Milano. A copy of this report (LIC811 Confidential Names) and the Licensee/Appeal Rights (LIC9058 01/16) were provided to Resident Services Coordinator, Evana Milano an electronic read receipt verifies receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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