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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603136
Report Date: 07/07/2022
Date Signed: 07/07/2022 05:13:26 PM


Document Has Been Signed on 07/07/2022 05:13 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:CORONADO RETIREMENT VILLAGEFACILITY NUMBER:
374603136
ADMINISTRATOR:ELIZABETH REYESFACILITY TYPE:
740
ADDRESS:299 PROSPECT PLACETELEPHONE:
(619) 437-1777
CITY:CORONADOSTATE: CAZIP CODE:
92118
CAPACITY:120CENSUS: 79DATE:
07/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:51 PM
MET WITH:Elizabeth NajeraTIME COMPLETED:
04:15 PM
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On July 7, 2022, at about 3:51 PM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced case management visit at the facility. LPA was greeted by Administrator, Elizabeth Najera and granted entry after identifying himself. LPA met with Administrator Najera and explained the purpose of the visit.

The facility self reported an incident to Community Care Licensing on July 1, 2022 regarding an incident that occurred on June 22, 2022. Reporting indicated that Resident 1 (LIC811 Confidential Names list provided to Administrator to identify R1) had an unwitnessed fall which resulted in a complaint of pain and evaluation at the hospital.

During today’s visit, LPA conducted a Health and Safety check of R1 and requested facility records. No deficiencies were cited at this time.

An exit interview was conducted with Administrator Najera and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) was provided.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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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