374603136-1-25-2024-08-AS-LTEZ-CZYW28-20240130155355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603136
Report Date: 01/25/2024
Date Signed: 01/25/2024 12:45:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
12/27/2023 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20231227093312

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:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	12:19 PM
MET WITH:	Liz Najera		TIME COMPLETED:	12:59 PM

ALLEGATION(S):

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Staff did not provide resident records to resident's authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Administrator Liz Najera and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of records review, interviews with facility staff and outside sources.

It was alleged that staff did not provide resident records to resident's authorized representative It was reported to CCL that as of December 13, 2023 no facility records have been produced for Resident 1 (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) Interview with Administrator revealed they have been in frequent contact with R1's responsible party as well as R1's authorized representative for many months.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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-20231227093312

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CORONADO RETIREMENT VILLAGE	FACILITY NUMBER: 374603136
	VISIT DATE: 01/25/2024

NARRATIVE

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Administrator further stated that the Licensee advised her on approximately September 2023 that she would compile all of R1's facility records and the Licensee would be in charge of sending out any facility records request for R1.

Licensee stated that on September 23, 2023 they received a subpoena from R1's authorized representative to send them "all of the documents." On September 28, 2023 Licensee emailed the facility records to the authorized representative. On December 27, 2023 an employee of the authorized representative called the licensee and stated that they were missing some of the resident's documents from January 1, 2022 through December 23, 2023. Licensee stated that they would resend the requested attachments to the authorized representative.

LPA records review revealed that a declaration of custodian of records was signed and dated on September 28, 2023 by the Licensee. Records review further revealed that over 400 pages of resident records were emailed to the authorized representative on September 28, 2023. The records emailed spanned from 2021 through 2023 and included; resident assessment and care plans, admission agreement, physicians reports, medication orders, incident reports, hospital discharge forms, medication refill orders and professional communication notes, etc.

Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid.

An exit interview was conducted with Liz Najera. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Liz Najera whose signature below verifies receipt of these rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

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