374600890-4-21-2023-08-AS-SJAB-CR7U42-20230424151425

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600890
Report Date: 04/20/2023
Date Signed: 04/21/2023 08:05:39 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2023 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20230412163216

FACILITY NAME:	ATRIA COLLWOOD		FACILITY NUMBER:	374600890
ADMINISTRATOR:	ARTEAGA, IRMA		FACILITY TYPE:	740
ADDRESS:	5308 MONROE AVE		TELEPHONE:	(619) 286-3583
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	185	CENSUS: 81	DATE:	04/20/2023
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Business Director Maritza Maezee		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Licensee did not provide non-skid mat for shower

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to open an investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Business Director Maritza Maezee.

On April 12, 2023, Community Care Licensing (CCL) received a complaint alleging facility shower did not have a non-skid mat. During the investigation, LPA Strong collected pertinent facility records, conducted interviews, and conducted a facility inspection. During facility inspection conducted on April 20, 2023, LPA Strong observed two resident showers without non-skit mats. Interview with residents of those rooms revealed that the showers have never had non-skid mats or strips. Interview with staff revealed that facillity does not provide non-skid mats to residents in care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 08-AS-20230412163216

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA COLLWOOD	FACILITY NUMBER: 374600890
	VISIT DATE: 04/20/2023

NARRATIVE

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Based on interviews and observations, a preponderance of evidence exists to support the allegation that licensee did not provide non-skid mat for shower. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Business Director Maritza Maezee, 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.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 08-AS-20230412163216

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA COLLWOOD	FACILITY NUMBER: 374600890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/04/2023 Section Cited CCR 87303(e)(5)	1 2 3 4 5 6 7	87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to provide non-skid mats or strips in bathtubs or showers by 5/4/2023.
	8 9 10 11 12 13 14	Based on observations and interviews the licensee did not provide non-skid mats or strips in bathtubs or showers in 2 of 81 persons in care [R1 and R2] which posed a safety risk to persons in care.”	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2023 and conducted by Evaluator Iby Strong

COMPLAINT CONTROL NUMBER: 08-AS-20230412163216

FACILITY NAME:	ATRIA COLLWOOD		FACILITY NUMBER:	374600890
ADMINISTRATOR:	ARTEAGA, IRMA		FACILITY TYPE:	740
ADDRESS:	5308 MONROE AVE		TELEPHONE:	(619) 286-3583
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	185	CENSUS: 81	DATE:	04/20/2023
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Business Director Maritza Maezee		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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9

Licensee did not place grab bar in required location

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to open an investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Business Director Maritza Maezee.

On April 12, 2023, Community Care Licensing (CCL) received a complaint alleging facility did not place grab bars in required location. According to allegation, Resident 1's (R1) room does not have enough grab bars throughout room.

During investigation LPA Strong collected pertinent facility records, conducted interviews, and conducted a facility inspection. During facility inspection conducted on April 20, 2023, LPA Strong observed multiple resident bathrooms with grab bars next to the toilet and shower as required by regulation. Records collected for R1 did not reveal need for additional grab bars. Interview with staff revealed all resident bathrooms contain grab bars where required.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20230412163216

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA COLLWOOD	FACILITY NUMBER: 374600890
	VISIT DATE: 04/20/2023

NARRATIVE
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 9909-A Based on LPA's interviews, and observations there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Business Director Maritza Maezee, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

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