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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600890
Report Date: 12/21/2021
Date Signed: 12/22/2021 08:23:23 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:ARTEAGA, IRMAFACILITY TYPE:
740
ADDRESS:5308 MONROE AVETELEPHONE:
(619) 286-3583
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:185CENSUS: 94DATE:
12/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Regional Vice President Julie WieseTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent case management visit to cite a deficiency identified during a prior-opened investigation. LPA was greeted by and identified himself to receptionist Karen Eugene. LPA then met and discussed the purpose of the visit with Regional Vice President Julie Wiese.

On February 4th, 2021, licensee self-reported an incident about inappropriate sexual touching between Staff Member 1 (S1) and Resident 1 (R1) that occurred on January 29th, 2021, which licensee learned about through R1’s family member. [See attached LIC 811 Confidential Names list for a description of S1.] Licensee immediately notified CCLD, the San Diego Police Department (SDPD), and the San Diego County Long-Term Care Ombudsman, and suspended S1’s employment pending further investigation. CCLD’s investigation consisted of a review of pertinent resident, staff, police, and text message records, as well as interviews of relevant residents, staff, and outside sources. The Department’s investigation revealed that S1 engaged in conduct inimical and sexual abuse towards residents in care.

According to interview of R1 and corroborated by S1’s own admission: On the evening of January 29th, 2021, S1 entered R1’s private bedroom. S1 took R1’s hand and placed it on S1’s crotch. R1 immediately pulled their hand away. R1 and S1 each stated the contact was non-consensual. Although R1 did not mention this, S1 also confessed to kissing R1 mouth-to-mouth with tongue. [R1 was cognitively competent.]

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 12/21/2021
NARRATIVE
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[CONTINUED FROM LIC 809] Interview of R1, S1, and outside sources revealed that S1 also abused Resident 2 (R2). On the evening of December 29th, 2020, S1 entered R2’s private bedroom and kissed them mouth-to-mouth with tongue. S1 undid their pants and exposed their genitals to R2. S1 then placed R2’s hand on their genitals. S1 and R2 both corroborated that the above actions occurred. S1 said these acts were consensual, but R2 said they were not. [R2 was cognitively competent.]

According to SDPD interviews and records review, on March 19th, 2021, S1 was arrested for violating California Penal Code 288(c)(2) Lewd Act by Caretaker on Dependent Adult and California Penal Code 314 Indecent Exposure, as a result of the above-described actions of S1 against R1 and R2. Licensee terminated S1’s employment. S1 spent 10 days in jail, then was released on bond after posting a $25,000 bail. The San Diego County District Attorney’s office stated S1 subsequently “plead guilty to a felony” and was “granted probation.”

S1 also admitted to having an on-going consensual sexual relationship with Resident 3 (R3) that involved kissing and performing oral sex on each other. Interview of R3 corroborated that they had sex with S1, and that their interaction was consensual. [R3 was cognitively competent.] S1’s sexual relations with R3 did not violate California Penal Code, since they occurred between two consenting adults. However, R3 was an elder dependent adult in care at the time of the relationship. According to CCLD’s Index of Decisions Relied Upon as Precedent, In re Bacud, 99 CDSS 01, "Sexual relationship between facility personnel and a consenting adult client in care constitutes a breach of the fiduciary relationship between a caregiver in a position of trust and the client." S1’s conduct with R3 still reflected “a failure to consider his duty as a care provider or the best interests of the client, thus constituting ‘conduct inimical.’”


S1 was an agent of the licensee during the above acts, which also occurred on facility premises. Based on records and interviews, a deficiency is being cited per California Code of Regulations, Title 22; see attached LIC 809-D. A plan of correction was jointly developed with Wiese and an exit interview was conducted. A copy of this report, the LIC 811 Confidential Names list, 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: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2022
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities: “…residents in privately operated residential care facilities shall have all of the following personal rights:…to be free from mental, physical, or sexual abuse.” This requirement is not met, as evidenced by:
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Based on records and interviews, Licensee’s staff caused sexual abuse on 2 residents [R1 and R2] of 93 in care, which posed an immediate personal rights risk to persons in care.
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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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021
LIC809 (FAS) - (06/04)
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