374600890-12-16-2025-08-AS-DNGN-DPESCE-20251216124526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600890
Report Date: 12/16/2025
Date Signed: 12/16/2025 12:46:31 PM

Document Has Been Signed on 12/16/2025 12:46 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ATRIA COLLWOOD		FACILITY NUMBER:	374600890
ADMINISTRATOR/ DIRECTOR:	JULIA LOPEZ		FACILITY TYPE:	740
ADDRESS:	5308 MONROE AVE		TELEPHONE:	(619) 286-3583
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY: 185		CENSUS: 95	DATE:	12/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Community Business Director Kitty Totorica		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dang Nguyen made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Julia Lopez and Community Business Director Kitty Totorica. During today’s visit, LPA briefly toured the lobby area, interviewed managers, and reviewed a selection of employee/personnel records. During review of personnel files, LPA observed, and manager interview confirmed: One (1) of forty-six (46) employes, Staff #1 [S1], did not have a Criminal Background Clearance to work, as required. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] S1 had worked at the facility since March 2024. For two (2) of five (5) sampled personnel records [Staff #2 (S2) and Staff #3 (S3)], Licensee did not have on file a copy of that employee’s LIC503 Health Screening (or similar proof of a pre-employment physical exam with a physician), as required. (Both caregivers had proof of a negative Tuberculosis result, however.) For one (1) of five (5) sampled personnel records (S3), Licensee did not have proof that the employee had current First Aid Training from persons qualified by such agencies as the American Red Cross, as required. S3 was direct care staff. [CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/16/2025

NARRATIVE

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[CONTINUED FROM LIC 809]

Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection.

Three (3) deficiencies were cited today per California Code of Regulations, Title 22 (see the attached LIC809-D pages). Since one of these deficiencies was regarding a staff background clearance, and immediate civil penalty of $500 was assessed (refer to the LIC421-BG page). Plans of Correction were jointly formed with the Licensee.

An exit interview was conducted with the Executive Director Julia Lopez and Community Business Director Kitty Totorica, to whom a copy of this report, the LIC809-D pages, the LIC421-BG page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/16/2025 12:46 PM - It Cannot Be Edited

Created By: Dang Nguyen On 12/16/2025 at 12:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ATRIA COLLWOOD	FACILITY NUMBER: 374600890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87335(e)(2)

87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department…” This requirement was not met, as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and manager interviews, Licensee did not ensure that 1 of 46 staff (S1) obtained a California clearance or a criminal record exemption as required by the Department, prior to working in the licensed facility. This posed an immediate safety risk to 95 of 95 residents [Resident #1 (R1) through Resident #95 (R95)] in care.
	POC Due Date: 12/16/2025
	Plan of Correction
1 2 3 4	S1 was not on duty today. Licensee agreed to immediately remove S1 from the work schedule and instruct them to complete LiveScan fingerprinting. This resolved the immediate risk. Licensee agreed to keep S1 off-duty until receipt of confirmation of a successful background clearance for S1 from CDSS.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/16/2025 12:46 PM - It Cannot Be Edited

Created By: Dang Nguyen On 12/16/2025 at 12:22 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ATRIA COLLWOOD	FACILITY NUMBER: 374600890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

87412 Personnel Records: a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.” This requirement was not met, as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and manager interviews, Licensee did not ensure that 2 of 5 sampled staff (S2 and S3) records contained a health screening, as specified in Section 87411, Personnel Requirements – General. This posed a potential health risk to 95 of 95 residents [Resident #1 (R1) through Resident #95 (R95)] in care.
	POC Due Date: 01/16/2026
	Plan of Correction
1 2 3 4	Licensee agreed to have S2 and S3 each complete an LIC503 Health Screening form (or equivalent document), evidencing that a doctor has determined each staff healthy enough to fulfill the job functions for which Licensee hired them for. (Since both employees have existing written proof negative TB result, the TB component does not need to be repeated to satisfy this POC.) Licensee agreed to E-mail copies of S2 and S3’s LIC503 forms to LPA, by the POC due date.

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements – General: “(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.” This requirement was not met, as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and manager interviews, Licensee did not ensure that 1 of 5 sampled staff (S3) records contained proof of current First Aid Training from persons qualified by such agencies as the American Red Cross. This posed a potential health risk to 95 of 95 residents [Resident #1 (R1) through Resident #95 (R95)] in care.
	POC Due Date: 01/16/2026
	Plan of Correction
1 2 3 4	Licensee agreed to have S3 complete First Aid Training. Licensee agreed to E-mail a copy S3 new biennial first aid card or certificate to LPA, by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

LIC809 (FAS) - (06/04)

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