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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600890
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:43:28 PM


Document Has Been Signed on 02/29/2024 03:43 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:ATRIA COLLWOODFACILITY NUMBER:
374600890
ADMINISTRATOR:JULIA LOPEZFACILITY TYPE:
740
ADDRESS:5308 MONROE AVETELEPHONE:
(619) 286-3583
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:185CENSUS: 84DATE:
02/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Executive Director Julia LopezTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Julia Lopez, Executive Director, to discuss the purpose of the visit.

Today's visit is in response to the self reported incident of second degree burns regarding Resident 1 (R1 - see LIC811 Confidential Names List).

LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date.

An exit interview was conducted with Julia Lopez, Executive Director, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
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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