<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603136
Report Date: 05/01/2024
Date Signed: 05/28/2024 04:35:06 PM


Document Has Been Signed on 05/28/2024 04:35 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
SO. CAL AC/SC, 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: 73DATE:
05/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Elizabeth Najera, AdministratorTIME COMPLETED:
09:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Daniel Pena, conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose to Wellness Director, Maria Moellman. Liz Najera, Administrator, later joined LPA and was briefed on the visit.

Today's visit was in response to an Incident Report submitted to the Department, for Resident 1 (R1). Per facility reporting, R1 sustained a fall on 04/06/2024 which resulted in two (2) spinal fractures. Reports indicate R1 was transported to the hospital and underwent surgery. Per Ms. Moellman, R1 was transferred to a rehabilitation facility after hospitalization and the facility is awaiting notice as to whether R1 will return to the community.

LPA conducted a review of R1's pertinent records and interviewed staff. No health and safety concerns were identified and no deficiencies were cited during today's visit.

An exit interview was conducted with Administrator Najera, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1