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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600890
Report Date: 05/29/2024
Date Signed: 05/30/2024 11:49:27 AM

Substantiated


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
05/21/2024 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20240521140128
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: 92DATE:
05/29/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Maintenance Director Omar ZamudioTIME COMPLETED:
04:49 PM
ALLEGATION(S):
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Facility staff do not maintain fire alarm system in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Debbie Correia, conducted a follow up visit to a complaint investigation. The LPA introduced herself to the facility Receptionist Griselda Pacheco then met with Maintenance Director (MD) Omar Zamudio and disclosed the purpose of the visit.

The Department's investigation included staff and outside source interviews, and facility records reviews.

It was alleged the facility does not keep their fire alarm system in good repair. A facility records review revealed on April 9, 2024, the facility underwent a fire inspection conducted by a contracted company. Records revealed the inspection yielded six deficiencies. An interview conducted with Outside Source1 (OS1) and a records review revealed the facility repaired two of the deficiencies identified during the inspection, however there were four other deficiencies the facility has not repaired.

This is an amended version of the original report dated 5/29/24.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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 3
Control Number 08-AS-20240521140128
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: 05/29/2024
NARRATIVE
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Based on LPA's interviews and a facility records review, the above allegation is substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met.

LPA Correia conducted an exit interview with MD Zamudio. At the time of the exit interview MD Zamudio was notified a copy of the Complaint Investigation Reports (LIC9099 and LIC 9099D) and Licensee Rights (LIC9058 01-2016) will be provided at the conclusion of the visit. Signature on this report acknowledges receipt of the documents.




This is an amended version of the original report dated 5/29/24.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240521140128
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2024
Section Cited
CCR
87203
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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life... against fire and panic. (1) Nonambulatory persons.
(2) Bedridden persons

This requirement was not met as evidenced by:
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Maintenance Director Zamudio agreed to contract with an outside agency to repair the doors indentified during the fire inspection by the POC due Date.

LPA will conduct a visit to confirm POC completion.
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Based on interviews and record reviews the Licensee did not address 4 facility doors that did not pass a fire system inspection (conducted on April 9,2024) due to the doors not latching or dragging.

This posed an immediate threat tol 92 residents in care.


This is an amended version of the original report dated 5/29/24.
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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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3