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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603136
Report Date: 03/12/2024
Date Signed: 03/12/2024 01:30:02 PM

Substantiated


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
08/07/2020 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20200807104355
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: 67DATE:
03/12/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Liz Najera, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff dropped resident resulting in multiple fractures.
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced complaint visit at the facility to close out a complaint. LPA gained access to the facility and met with Administrator, Liz Najera, and explained the purpose of the visit which was to deliver findings for the above allegations.

The Department’s investigation consisted of record reviews, interviews with staff, residents and outside sources.

It was alleged that staff dropped resident resulting in multiple fractures. Interviews revealed that on July 23, 2020, on or about 1:00 PM Staff 1 (S1) indicated they were transferring Resident 1 (R1) from the wheelchair to their bed by themself. R1 became combative and S1 believed they were going to lose control of R1, so S1 assisted R1 to the floor. Interviews revealed R1 slid between S1’s legs and R1’s legs twisted as they slid. S1 conducted a body check and observed a skin tear with blood on their left knee and during the check, R1 complained of left knee pain. A review of the facility training protocol for a Manual Transfer, Lifting and Repositioning instructions stated, “Do not attempt to lift or transfer residents by self; If a coworker is not available, ask additional assistance from Med-Tech or Supervisor.” During the interview with the Med-Tech, they confirmed that training policy/protocol mandates “two-person assist” when transferring residents. Interviews revealed they have observed caregivers transfer R1 in and out of bed by themselves because R1 is small and does not weigh much. However, interviews revealed that S2 has always advised other staff to use two-person assist when transferring R1 per facility policy/protocol. Hospital records dated July 20, 2020, revealed that R1 suffered fractures of their Bilateral Hips and Femur and had surgery on July 25, 2020 for repair.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
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
08/07/2020 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20200807104355

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: 67DATE:
03/12/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH: Liz Najera, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff neglected resident resulting in a urinary tract infection
Neglect/lack of care and supervision by facility staff resulting in dehydration
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced complaint visit at the facility. LPA gained access to the facility and met with Administrator, Liz Najera, and explained the purpose of the visit which was to deliver findings for the above allegation.

The Department’s investigation consisted of record reviews, interviews with staff and outside sources. It was alleged that staff neglected resident resulting in a urinary tract infection and severe dehydration. Interviews revealed that Resident 1(R1) had a call button beside their bed and that they were normally good about calling for assistance. Interviews with staff revealed the water station was located just outside R1’s room. Interviews also revealed that staff would do rounds every two hours and would encourage R1 to drink water during their visits. R1 would drink through a straw while the staff member assisted them by holding the glass of water.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20200807104355
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: 03/12/2024
NARRATIVE
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Interviews revealed that the caregivers are responsible for ensuring water is always available for the residents and encouraging them to drink water. Staff would give R1 their medication in the dining area during breakfast and lunch. R1 always requested a glass of water to take their medications. Interviews revealed several staff members would always make water available to R1 and encourage them to drink it during their visits. However, R1 did not like water and would often refuse. Interviews revealed a cup of water was kept on a night stand next to R1’s bed. R1 in addition to water was also provided Ensure protein drinks several times a day to supplement for their lack of fluid intake and juice during meals. Interviews revealed that R1 liked Ensure and they normally finished the drink when it was provided to them. After a review of Medical Records from Sharp Memorial from R1’s visit on 7/23/2020, there was no indication/mention of dehydration. Dehydration was first reflected in Scripps Green Hospital medical records after R1 was transferred on 7/24/2020. Interviews with outside sources stated they did not believe facility staff would be able to adequately evaluate a resident for dehydration due to their lack of training. The allegations of staff neglected resident resulting in a urinary tract infection and neglect/lack of care and supervision by facility staff resulting in dehydration is unsubstantiated.

Based on the evidence obtained from interviews, and records review, the complaint allegations are unsubstantiated. An exit interview was conducted with Liz Najera, Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20200807104355
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by:
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Licensee stated that S1resigned on 12/26/2022. Licensee stated they will provide staff training from an outisde source on two person transfer assists, combative residents, and staff compentency. POC due to CCL by 03/22/2024 with sign in sheet and training materials.
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Based on interviews and records review, the licensee did not retain competent personnel to provide the services necessary to meet resident needs in 1 of 86 persons in care [R1] which posed an immediate Health, Safety, and Personal Rights risk to persons in care.
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Type A
03/22/2024
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care

Incidental Medical Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…

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Licensee stated they conduct mid week trainings every week on procedures and safety checks. Licensee will provide training from an outside source on Responding properly to residents care needs. POC due to CCL by 03/22/2024 with sign in sheet and training materials.
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Based on interviews and review of records, the licensee did not immediately telephone 9-1-1 for the injury R1 sustained in 1 of 86 persons in care which posed an immediate Health risk to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20200807104355
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: 03/12/2024
NARRATIVE
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 On August 6, 2020, R1 passed away due to Failure to thrive and Granulomatous disease. The death report also stated that other significant conditions contributing to the death were injuries sustained from a fall on July 23, 2020 and Cardiac Disease. Based on records and interviews conducted, R1’s fall may have been prevented if S1 was following facility policy/protocol when transferring R1; therefore, the allegation of neglect resulting in R1’s fall and subsequent death is substantiated.

It was alleged that staff did not seek medical attention for resident in a timely manner.
Interviews revealed R1’s neighbor (R2) was returning from dinner, and they walked to R1’s room to visit them. Upon arrival, R1’s door was open and R1 was lying in bed. Interviews revealed R2 observed R1 to have a distressed look on their face and they reached up toward R2 with their hand. Interviews revealed R1’s hand was very clammy. R1 expressed that they were in a lot of pain and R1 begged R2 to get them some help. Interviews revealed R2 immediately went to the nurse’s station and advised a nurse that R1 was in pain and needed to go to the hospital. Staff called for an ambulance and R1 was transported to the hospital. A review of records reviewed from the ambulance company show that they received the call from Cornado Retirement Village at 7:40 PM and immediately dispatched an ambulance to the facility. The ambulance arrived at the facility at 7:51 PM and transported R1 to the hospital. The ambulance arrived at the hospital at 8:33 PM.

A review of the Ambulance Service Incident/Response report revealed that facility staff were unsure if R1 hit their head and that R1 was given Tylenol for pain, but they weren’t able to state the time that the medication was given. The report also revealed that staff advised Emergency Medical Technicians (EMT) that the resident was observed increasingly lethargic since their fall at 1:00 PM. The report also documented that staff described R1 as normally talkative and polite, but on this day R1 was refusing to let staff touch them. When EMTs assessed R1, R1 displayed 10/10 sharp pain in right hip and bilateral lower extremities that worsened significantly upon movement or palpitation and yelped in pain. EMTs asked R1 what happened but R1 couldn’t recall the fall. The report documents bilateral bruising on anterior aspect of R1’s shins. R1 also had a skin tear on the right knee, covered with a band aid.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 08-AS-20200807104355
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: 03/12/2024
NARRATIVE
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The facility’s Training/Policy states the following: … emergencies include, but are not limited to: Shortness of breath, bleeding, trauma, chest pain or other notable pain, fainting, fall, stroke, unconsciousness, suicide thoughts/action, severe dehydration/weakness, dizziness, delirium, aggressive behavior, or any life-threatening situations, Do Not delay in guessing or assuming; The Med-Tech on shift or attending staff must immediately call 911. Based on staff and resident interviews, a review of the Ambulance Service Incident/Response report, and review of the facility’s Training/Policy, the allegation of staff neglecting to immediately telephone 9-1-1 for an injury is substantiated.

Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8, and are noted on the attached LIC9099-D.

An immediate civil penalty of $500 was assessed for the following violation:
Incidental Medical and Dental Care.
Incidental Medical Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…
At this time, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division

Based on the evidence obtained from interviews, and records review, the complaint allegations are substantiated. An exit interview was conducted with Liz Najera, Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6