374603136-12-7-2023-08-AS-SJAB-CYW23R-20231226160247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603136
Report Date: 12/07/2023
Date Signed: 12/07/2023 09:22:27 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
06/29/2022 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20220629133454

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: 57	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Erika Avalos, Office Manager		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Resident hit by unknown adult while in care, resulting in injury

INVESTIGATION FINDINGS:

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On 12/7/2023, at about 8:55 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 6/29/2022, the Department received a complaint, alleging a resident was hit by an unknown adult while in care, resulting in injury. The Department’s investigation consisted of LPA observation, record reviews, and interviews with residents, staff and outside sources.

Record reviews showed that the incident was reported by facility staff as an unwitnessed fall. Resident 1 (R1)’s records showed that they have Mild Cognitive Impairment (MCI), history of falls, and visual impairment. The facility records indicate staff reported an incident involving this resident on 6/22/22 where the resident experienced an unwitnessed fall. The resident was transported to the hospital where they were diagnosed with a bruise to the forehead. None of the records associated with the 6/22/22 incident

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: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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-20220629133454

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: 12/07/2023

NARRATIVE

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reflect R1 was or reported being assaulted.

The alleged incident occurred in the CRV Memory Care Unit. A sample of Memory Care Unit residents were interviewed but due to their medical/physical conditions could not serve as qualifiable witnesses. In their interview, R1 said they were in bed and were asleep when "a man hit me." R1 did not know who the man was. R1 never saw the person before. R1 said the man struck them in the forehead once. R1 told a family member but did not report the incident to CRV employees. R1 said they were seen by a doctor but received no injury. R1 has not seen the man again. When asked, R1 said they felt safe at CRV. When asked, R1 said no CRV staff or another resident hit them. R1 said there was no witness to the incident.

Staff interviews yielded no conclusive evidence to support the allegation. Staff generally said they were familiar with R1 and knew they had Dementia. None of the staff witnessed any person strike R1 at any time.

Interviews with outside sources did not produce information to corroborate the allegation. LPA observation during a walk through of the facility did not show evidence that R1 had been assaulted. A law enforcement officer responded to the facility, but no arrest was made.

The Department has investigated the allegation that a resident was hit by an unknown adult while in care, resulting in injury. Based on interviews and record reviews the investigation failed to produce sufficient evidence to support the allegation. The preponderance of evidence standard was not met; therefore, the allegation is deemed 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: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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