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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603136
Report Date: 10/30/2020
Date Signed: 10/30/2020 12:48:50 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/03/2019 and conducted by Evaluator Daniel Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20191003160647
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: 66DATE:
10/30/2020
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elizabeth Reyes, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident had black mold growing in their room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Tele Visit, due to Covid-19, to deliver findings on the above-mentioned allegation. LPA conducted an entrance interview with Liz Reyes, Administrator and discussed the purpose of the visit.

The Department’s investigation consisted of interviews, record review and facility inspection. LIC811 Confidential Names was provided to the Administrator to identify Resident #1 (R1).

It was alleged that black mold was growing in R1’s room (226). Interviews revealed conflicting observations of this allegation. However, at least once while R1 resided at the facility, a staff observed mold in R1’s shower beneath strips of non-skid tape. Staff interviewed confirmed they can identify mold which, according to the Mayo Clinic, can cause nasal stuffiness, throat irritation, coughing or wheezing, eye irritation, or, in some cases, skin irritation. Staff removed and treated the mold and applied new non-skid tape. There were no other instances where mold was observed in R1’s room. Photographs
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony GirolamiTELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 323-4520
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
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 7
Control Number 08-AS-20191003160647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CORONADO RETIREMENT VILLAGE
FACILITY NUMBER: 374603136
VISIT DATE: 10/30/2020
NARRATIVE
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obtained during the investigation, displayed brown spots on the surfaces of the vanity, walls and shower floor, which could not be confirmed to be mold.

This Department has investigated the allegation that mold was growing in R1’s room and has found that, based upon interviews and review of records and photographs, the preponderance of the evidence standard has been met. Therefore, this allegation has been deemed Substantiated.

This deficiency is noted on the attached 9099-D and is cited in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with Administrator Reyes and a copy of this report, Appeal and Licensee Rights (LIC 9058 01/16) and Confidential Names (LIC 811) were provided to Administrator Reyes via electronic mail. An electronic mail confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20191003160647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CORONADO RETIREMENT VILLAGE
FACILITY NUMBER: 374603136
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2020
Section Cited
CCR
87303
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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of
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The immediate risk to the resident was removed when staff removed and treated the area. Licensee agrees to inspect all resident rooms and address any evidence of mold. Licensee will prepare a report of completion to CCLD by November 30, 2020.
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residents, employees and visitors. This requirement was not met as evidenced by: Based on record review and interviews, black mold was observed by staff in R1’s shower. This posed a potential health risk to R1.
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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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/03/2019 and conducted by Evaluator Daniel Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20191003160647

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: DATE:
10/30/2020
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elizabeth Reyes, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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- Staff does not clean resident's room
- Licensee failed to render services as stated in the admission agreement
INVESTIGATION FINDINGS:
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It was also alleged staff does not clean resident’s room. Investigation consisted of interviews with staff, outside sources and review of records and photographs. (LIC811 Confidential Names was provided to Administrator to identify R1).

Photographs of R1’s room depicted clothing stuffed in drawers in a disorganized manner, marks on the vanity, walls and shower, dirty dishes, debris on the carpet and presence of cat feces. Record reviews revealed that the Admission Agreement stipulates that residents are responsible for picking up their pet’s waste. Despite this, staff interviews revealed they routinely cleaned up after R1’s cat. Interviews also indicated that facility staff unclogged R1’s toilet and shower several times because R1 would throw cat litter down the toilet and shower drain. Staff interviews positioned that the markings on the walls, vanity and shower were food and cat feces thrown there by R1.

According to the facility, R1’s apartment received daily bed making and trash removal
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20191003160647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CORONADO RETIREMENT VILLAGE
FACILITY NUMBER: 374603136
VISIT DATE: 10/30/2020
NARRATIVE
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and whenever R1 had occasional BM accidents staff would clean it up immediately. An outside source visited R1’s room in September 2019 and described the room as clean. Interviews also indicated that R1 would take dirty laundry and shove it back into their dresser drawers.

Staff would have to sort the soiled laundry and wash it. R1 constantly changed their clothes and did not put them away or in the dirty laundry bin. Facility staff said whenever they received a complaint regarding housekeeping in R1’s room they immediately cleaned it.

Also alleged is the Licensee failed to render services as stated in the Admission Agreement. Records indicated that in addition to base rent, the facility charged additional fees for laundry and food tray service. Food tray service charges were instituted for meals delivered and served to the resident’s room upon request. The billing records clearly documented the charges which were $100 per month for laundry service and $7.00 for each instance of food tray service. Even though photographs reviewed showed resident clothing in various states of disarray, facility interviews consistently asserted that laundry service was rendered but the resident changed clothes several times a day, leaving their clothing in disarray. Staff interviews also stated that R1 would take soiled clothing and stuff it in their dresser drawers.

This Department has investigated the allegations that staff does not clean R1’s room and the Licensee failed to render services as stated in the Admission Agreement. The Department has determined that, based upon interviews and record review, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Administrator Reyes and a copy of this report, Appeal and Licensee Rights (LIC 9058 01/16) and Confidential Names (LIC 811) were provided to Administrator Reyes via electronic mail. An electronic mail confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/03/2019 and conducted by Evaluator Daniel Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20191003160647

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: DATE:
10/30/2020
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elizabeth Reyes, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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It was also alleged the Licensee illegally evicted R1. Investigation consisted of interviews with staff, outside sources and review of records. (LIC811 Confidential Names was provided to Administrator to identify R1).

Interviews with staff and outside sources consistently revealed that R1 failed to pay outstanding charges. Allegedly, the fees were unpaid because the facility did not render services previously mentioned. As previously indicated, there was insufficient evidence to corroborate the Licensee failed to render services.

According to an outside source, the resident regularly failed to pay R1’s rent on time. This witness indicated that the facility presented the resident several opportunities to pay past charges but they failed to pay them. By record review, it was determined that the facility served the resident’s responsible person with a Delinquent Rent notice dated July 30, 2019, essentially stating the monthly rent and level of care needed to be paid.

The letter continued stating if R1’s account was not paid a 30-day notice of eviction
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20191003160647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CORONADO RETIREMENT VILLAGE
FACILITY NUMBER: 374603136
VISIT DATE: 10/30/2020
NARRATIVE
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would be set forth as stated in the Admission Agreement. On August 26, 2019, the facility served the resident with a second letter requesting overdue fees to be paid. The letter stated if the balance owed was not paid by September 1, 2019, the facility would serve the resident with a formal 30-Day notice of eviction. The resident voluntarily moved from the facility on September 16, 2019.

This Department has investigated the complaint alleging the Licensee illegally evicted R1 and has determined that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Administrator Reyes and a copy of this report, Appeal and Licensee Rights (LIC 9058 01/16) and Confidential Names (LIC 811) were provided to Administrator Reyes via electronic mail. An electronic mail confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 7