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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603136
Report Date: 02/28/2024
Date Signed: 02/28/2024 05:06:51 PM


Document Has Been Signed on 02/28/2024 05:06 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
CCLD Regional Office, 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: 68DATE:
02/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Elizabeth NajerasTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Elizabeth Najera.

Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/05/2024). According to the LIC624, during the early morning of 02/01/2024, Resident #1 (R1) had an unwitnessed fall. [See LIC 811 Confidential Names List for a description of R1.] Staff observed R1 on the floor and was assessing them for injuries when R1 had a seizure episode. 911 was called and R1 was hospitalized.

During today’s visit, LPA performed a brief facility tour. As of the date of LPA’s visit, R1 had not yet returned to the facility. LPA collected copies of and reviewed pertinent care records. LPA also interviewed relevant staff.

No deficiencies were cited during today's visit.

LPA issued one (1) Technical Violation (TV) regarding reporting requirements (see LIC9102-TV). LPA also issued Technical Assistance (TA) regarding medical assessment and reappraisal (see LIC9102-TA).

An exit interview was conducted with Reyes, to whom a copy of this report, the LIC9102-TV, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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