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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600890
Report Date: 03/12/2021
Date Signed: 03/12/2021 02:31:19 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: 93DATE:
03/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:John BrennanTIME COMPLETED:
02:23 PM
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Licensing Program Analysts (LPAs) Natasha Persaud and Dang Nguyen conducted an unannounced case management tele-virtual visit, due to the COVID-19 pandemic. LPAs identified themselves and stated the purpose of the visit to facility administrator John Brennan.

The facility self-reported an incident about inappropriate touching between Staff Member 1 (S1) and Resident 1 (R1) that occurred on 01-29-21. The incident report stated that S1 had been suspended pending investigation. S1's employment was subsequently terminated.

On today’s date, LPAs briefly toured the facility, interviewed staff, and requested relevant care and administrative records. No deficiencies were cited during the visit.

An exit interview was conducted with the administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. An electronic read receipt confirmation was requested from the administrator upon receipt of documents. [See LIC811 Confidential Names list to identify Resident 1 and Staff 1].
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
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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