374603136-1-16-2024-08-AS-IESA-CZZTZP-20240131141041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603136
Report Date: 01/05/2024
Date Signed: 01/16/2024 06:45:07 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
06/27/2023 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20230627133539

FACILITY NAME:	CORONADO RETIREMENT VILLAGE		FACILITY NUMBER:	374603136
ADMINISTRATOR:	ELIZABETH REYES		FACILITY TYPE:	740
ADDRESS:	299 PROSPECT PLACE		TELEPHONE:	(619) 437-1777
CITY:	CORONADO	STATE: CA	ZIP CODE:	92118
CAPACITY:	120	CENSUS: 63	DATE:	01/05/2024
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Erika Avalos, Administrator		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

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Lack of supervision resulted in resident physical abuse by another resident which resulted in serious injury

INVESTIGATION FINDINGS:

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On 1/5/2024, at about 8:20 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to conclude a complaint investigation. LPA identified himself and discussed the allegations mentioned above with Erika Avalos, Office Manager.

On 06/27/2023, the Department received a complaint, alleging lack of supervision resulted in resident physical abuse by another resident which resulted in serious injury. The Department’s investigation consisted of LPA observation, record reviews, and interviews with residents, staff, and outside sources.

Resident 1 (R1) and Resident 2 (R2) were both admitted to Memory Care, have a diagnosis of dementia and suffer from severe cognitive impairment. Both residents have shown signs of aggression toward staff and or other residents, but the last documented incident occurred in March of 2023 when R1 punched a staff member and attempted to hit several residents. Both R1 and R2 had medication changes or increases to calm them and make them less aggressive. Prior to this incident, there were no prior incidents between R1 and R2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230627133539

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VILLAGE	FACILITY NUMBER: 374603136
	VISIT DATE: 01/05/2024

NARRATIVE

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Closed-circuit television system evidence was reviewed as part of this investigation. On the day of the incident, there was one staff member in the dining room supervising four residents. R1 was talking to another resident while R2 was standing on the other side of the room. R1 left talking to the resident and casually walked toward R2. The security video is blurry, but it appears that R1 tried to grab R2 by the arms and R2 pushed R1 away in a startled or defensive move. R1 fell to the ground.

Caregiver 1 (CG1) responded immediately and called for assistance on their handheld radio. Medication Technician (MT1) responded to the call for assistance. MT1 assessed R1 for injuries and called 911 to have R1 transported to the hospital to be evaluated.

According to CG1, they did not see the incident between R1 and R2 that caused R1 to fall. CG1 did not hear the conversation or any argument between them. Video review showed, R1 casually walked toward R2 without obvious signs that R1 was upset and an altercation between R1 and R2 was imminent. In fact, the video shows that R1 approached R2 and R2 was most likely defending himself from R1.

Based on the Department’s investigation, the allegation of Neglect/lack of supervision and care resulted in physical abuse of a resident by another resident, resulting in serious injury is Unsubstantiated.

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Office Manager, Avalos, whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

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