374600890-10-31-2023-08-AS-DNGN-CX62DT-20231031171852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600890
Report Date: 10/31/2023
Date Signed: 10/31/2023 05:19:12 PM

Document Has Been Signed on 10/31/2023 05:19 PM - It Cannot Be Edited

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 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: 96	DATE:	10/31/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Executive Director Julia Lopez		TIME COMPLETED:	05:30 PM

NARRATIVE

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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 Julia Lopez.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/18/2023). According to the LIC624: on 10/15/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] Shortly after, R1 was returned to the facility unharmed.

During today’s visit, LPA performed a welfare check on R1, finding they were indeed safe and unharmed. LPA toured the facility and tested staff alert devices/alarms on each of the facility’s exterior/perimeter doors, finding all were audibly working. LPA also collected copies of pertinent care records and interviewed R1 and relevant staff.

According to their latest LIC602 Physician’s Report (dated 04/07/2022), R1 did not have any cognitive impairment diagnosis and their doctor determined that they were able to safely leave the facility unassisted. R1’s doctor also wrote that they were not confused/disoriented, able to follow instructions, and able to communicate needs. R1 was also independent in Activities of Daily Living (ADLs).

Staff interviews showed: Aside from medication assistance, R1 was independent with all ADLs. Around 2:45 AM on 10/15/2023, staff responded to the facility’s front door being ajar. They saw R1 across the street, accompanied by a police officer, who walked R1 back to the facility. The police officer told staff that R1 had seen and approached their parked patrol car, which was near the facility. Following the incident, licensee performed a reappraisal of R1’s care needs and requested a new/updated LIC602 from R1’s physician.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/31/2023

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[CONTINUED ON LIC 809]

R1 corroborated the above timeline and told LPA they remembered laying down in bed to sleep on the evening in question, but could not recall how or why they subsequently exited the facility’s front door that night, or what they were looking for.

No deficiencies were cited during today's visit. However, LPA issued two (2) Technical Violations (TVs), regarding Reporting Requirements and regarding Delayed Egress Doors.

An exit interview was conducted with Lopez, to whom a copy of this report, the LIC9102-TV pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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