374600890-5-20-2024-08-AS-SJAB-D5JK3U-20240523073317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600890
Report Date: 05/17/2024
Date Signed: 05/20/2024 10:19:03 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
02/02/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20240202104641

FACILITY NAME:	ATRIA COLLWOOD		FACILITY NUMBER:	374600890
ADMINISTRATOR:	JULIA LOPEZ		FACILITY TYPE:	740
ADDRESS:	5308 MONROE AVE		TELEPHONE:	(619) 286-3583
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	185	CENSUS: 88	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Omar Zamudio Maintenance Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not provide resident with water.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Maintenance Director Omar Zamudio

On January 23, 2024 Community Care Licensing (CCL) received a complaint alleging staff did not provide resident with water. During the investigation, LPA Domingo conducted a facility inspection, collected pertinent records, and conducted interviews.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240202104641

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ATRIA COLLWOOD	FACILITY NUMBER: 374600890
	VISIT DATE: 05/17/2024

NARRATIVE

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Continued from LIC9099

According to allegation received, Resident 1 (R1), (Please refer to LIC811 confidential names list), stated that a facility staff did not bring R1 water when R1 requested water. LPA Domingo observed several unopened bottles of water. R1 was interviewed and R1 stated that the facility provided the bottled water and there are amble water bottles available. Outside Source 1 (OS1) stated that there are water bottles available to residents and water stations available at all times for residents. Staff 1 was interviewed and S1 provided a tour of all the water stations on all the floors, the dining area and staff provide water bottles to residents as needed.

LPA Domingo toured the facility and observed the multiple water stations, and water bottles throughout the facility. Resident 2 (R2) was interviewed and stated that there are no concerns regarding staff providing water bottles or water when requested. Outside Source 2 (OS2) was interviewed and OS2 stated that there has been no concerns regarding the availability of water when requested and there is water stations throughout the facility.

Based on interviews, and direct LPA observations a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Maintenance Director Omar Zamudio, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

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