374600890-12-30-2025-08-AS-DNGN-DPV4YJ-20251230183113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600890
Report Date: 12/30/2025
Date Signed: 12/30/2025 06:32:31 PM

Document Has Been Signed on 12/30/2025 06:32 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: 94	DATE:	12/30/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Community Business Director Kitty Totorica,Resident Services Director Ashley Baino-Jaimes, Maintenance Director Omar Zamudio		TIME VISIT/ INSPECTION COMPLETED:	07:00 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 conducted a return visit to continue a Required Annual Inspection that began on 12/16/2025. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Community Business Director Kitty Totorica. LPA also met with Resident Services Director Ashley Baino-Jaimes and Maintenance Director Omar Zamudio. According to the facility’s license, the facility has a maximum capacity of one-hundred-eighty-five (185) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Additionally, the facility has an approved waiver for ten (10) hospice care residents. Per LPA observation, care records, and staff interviews: During today’s inspection, there were a total of ninety-four (94) residents in care, of whom sixty-seven (67) were non-ambulatory, twenty-seven (27) were ambulatory, and none were bedridden. Two (2) of these residents were under hospice care. LPA reviewed records for multiple residents and multiple staff. LPA interviewed multiple residents and multiple staff. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility, and inspected all common areas and multiple resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 72 F. [CONTINUED ON LIC 809-C, 1 of 2]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

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 7

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)

Page: 2 of 7

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: 12/30/2025

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
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809] Where tested, hot water temperature at taps accessible to residents were all compliant: Room #101 Sink was 111.9 F, Room #113 Sink was 116.1 F, Room #122 Sink was 111.7 F, Room #128 Sink was 115.3 F, Room #202 Sink was 113 F, Room #207 Sink was 117.5 F, Room #221 Sink was 107.1 F, Room #227 Sink was 114.4, Room #303 Sink was 108.1 F, Room #305 Sink was 107.4 F, Room #314 Sink was 107 F, Room #317 Sink was 109.2 F, Room #401 Sink was 106.9 F, Room #415 Sink was 108.9 F, and Room #425 Sink was 108 F. Appliances to preserve perishable food were also all compliant in temperature: Main Walk-In Refrigerator was 40 F. Freezers were 0 F. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No fireplaces, pools, or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Fire detection system, carbon monoxide detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE). Licensee presented proof of current business liability insurance.

During the facility tour, LPA observed, and manager interview confirmed: The facility has two (2) perimeter exit doors which have 15-second delayed-egress mechanisms. However, the facility’s existing Fire Clearance document (dated 02/15/2011) did not include approval for delayed-egress devices.

During a review of client records, LPA observed, and manager interview confirmed: For five (5) of five (5) sampled residents [Resident #1 (R1) through Resident #5 (R5)], Licensee did not have in their record of care the name, address, and telephone number of the residents’ dentist to be called in an emergency, as required. For one (1) of five (5) sampled residents (R1), Licensee did not have documentation that the resident received an annual routine visit (also known as an annual “physical” or “check-up”) with their respective licensed medical professional (or alternatively, documentation of the resident and responsible person’s refusal or such), as required.

[CONTINUED ON LIC 809-C, 2 of 2]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

LIC809 (FAS) - (06/04)

Page: 3 of 7

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: 12/30/2025

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
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809-C, 1 of 2]

Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the LIC809-D pages). Plans of Correction were jointly formed with the Licensee. LPA also issued Technical Assistance (TA) regarding periodically measuring residents’ body weights and regarding specific skills training for direct care staff (refer to the attached LIC 9102-TA pages).

An exit interview was conducted with Maintenance Director Omar Zamudio and Dining Services Director Fernando Soto. A copy of this report, the LIC 809-D pages, the LIC9102-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were during today’s visit. Copies of the same were E-mailed to Executive Director Julia Lopez, Resident Services Director Ashley Baino-Jaimes, Community Business Director Kitty Totorica, and Maintenance Director Omar Zamudio.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 12/30/2025 06:32 PM - It Cannot Be Edited

Created By: Dang Nguyen On 12/30/2025 at 05:00 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: 12/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(e)(2)

87705 Care of Persons with Dementia: “(e) Licensees that use delayed egress devices on exterior doors…shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of delayed egress devices.” This requirement was not met, as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and records review, Licensee used delayed egress devices on two (2) exterior doors, but did not ensure that the facility’s fire clearance included approval of delayed egress devices. This poses an immediate safety risk to 94 of 94 residents (R1 through Resident #94) in care.
	POC Due Date: 12/31/2025
	Plan of Correction
1 2 3 4	By the POC due date, Licensee agreed to E-mail an LIC200 Application and LIC9054 Local Fire Inspection Authority Information to the CCLD San Diego Regional Office (CCLASCPSanDiegoRO@dss.ca.gov), to begin the process of requesting a new fire inspection visit. Licensee should clearly print on the application, and reiterate in the body of the E-mail, its desire to gain fire department approval for use of delayed-egress devices on its existing two (2) exit doors. If the fire department later denies the request, License agrees to deactivate those devices.

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: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 12/30/2025 06:32 PM - It Cannot Be Edited

Created By: Dang Nguyen On 12/30/2025 at 05:29 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: 12/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(9)

87506 Resident Records: “(b) Each resident’s record shall contain at least the following information: (9) Name, address and telephone number of…[a] dentist to be called in an emergency.” This requirement was not met, as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and manager interview, for five (5) of five (5) sampled residents [R1 through R5], Licensee did not have in their record of care the name, address, and telephone number of the residents’ dentist to be called in an emergency, as required. This posed a potential health risk to persons in care.
	POC Due Date: 01/30/2026
	Plan of Correction
1 2 3 4	Licensee agreed to communicate with necessary parties to update the Facesheets for R1 through R5, to include the name, address, and telephone number for each resident’s dentist. If a resident does not have a preferred dentist, Licensee may list a generic/default one who can be called for emergencies, until a preferred one is provided. Licensee agreed to E-mail the updated Facesheets for R1 through R5 to LPA, by the POC due date. Licensee agreed to self-audit remaining Facesheets for dentist information.

Type B

Section Cited

CCR

87463(h)(1)

87463 Reappraisals: “(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.” This requirement was not met, as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and manager interview, Licensee did not ensure that 1 of 5 sampled residents (R1) had documentation of an annual routine visit with a licensed medical professional. This posed a potential health risk to persons in care.
	POC Due Date: 01/30/2026
	Plan of Correction
1 2 3 4	Licensee agreed to coordinate with the responsible person (RP) to ensure that R1 completes their annual routine physical/medical visit. (In cases where the RP refuses the annual visit, Licensee will document such refusal in writing.) Licensee agreed to send proof of completion to LPA, by the POC due date. Licensee agreed to self-audit remaining resident files to ensure completeness of documentation on this topic.

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: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document is an Amendment of Original Document on 02/18/2026 05:35 PM

Created By: Dang Nguyen On 12/30/2025 at 05:31 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
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: 12/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	LPA REMOVED THIS DEFICIENCY.
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

LIC809 (FAS) - (06/04)

Page: 7 of 7