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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600890
Report Date: 08/30/2021
Date Signed: 08/31/2021 09:14:32 AM

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:KATHLEEN MITCHELLFACILITY TYPE:
740
ADDRESS:5308 MONROE AVETELEPHONE:
(619) 286-3583
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:185CENSUS: 97DATE:
08/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Interim Executive Director Kris WaluzskoTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to follow up on events which licensee self reported to the Community Care Licensing San Diego Regional Office (RO). LPA was welcomed by and identified himself to receptionist Elizabeth Cardenas. LPA then met and discussed the purpose of the visit with Interim Executive Director Kris Waluzsko.

On 08-19-2021, the RO received two LIC624 Unusual Incident Reports regarding Resident #1 (R1) and Resident #2 (R2) being absent without leave from the facility (AWOL) [see LIC 811 Confidential Names list for a description of R1 and R2]. The first report stated that Resident #1 (R1) was observed across the street from the facility around 4:00 PM on 08-17-2021 unharmed, before being escorted back home by staff. The second report said Resident #2 (R2) was observed walking down the sidewalk in front of the facility around 1:30 PM on 08-18-2021 unharmed, before being escorted back home by staff.

During today’s visit, LPA briefly toured the facility and performed a welfare check on R1 and R2. LPA interviewed R1, R2, contracted home care staff, and the facility administrator. LPA also obtained copies of pertinent facility care records. No deficiencies were cited during today’s visit.

An exit interview was conducted with Waluzsko, to whom a copy of this report, the Confidential Names list (LIC 811), and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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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