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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603136
Report Date: 03/29/2021
Date Signed: 03/29/2021 10:36:24 AM



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
03/09/2020 and conducted by Evaluator Adam Hamer
COMPLAINT CONTROL NUMBER: 08-AS-20200309102027
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: 53DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Elizabeth Reyes, Administrator TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Licensee did not provide adequate supervision resulting in multiple falls.
Medication technicians did not have the required training.
Licensee did not administer medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Adam Hamer contacted Administrator Elizabeth Reyes and conducted an unannounced complaint investigation visit via FaceTime due to COVID-19. LPA gained access to the facility, identified himself, met with Ms. Reyes and discussed the purpose of the visit, which was to deliver findings for the above allegations.

The Department’s investigation included, but was not limited to, interviews with outside sources, staff and the facility’s administrator. Facility and medical records were also obtained by the Department and reviewed for pertinent evidence.

The Department received a complaint alleging that staff did not provide adequate supervision which resulted in Resident #1 (R1 – See LIC 811 Confidential Names List) having multiple falls. The other allegations allege that medication technicians did not have the required training and that licensee did not administer medications as prescribed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam HamerTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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 3
Control Number 08-AS-20200309102027
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: 03/29/2021
NARRATIVE
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The Department conducted a facility records review and interviewed facility staff who expressed that R1 was constantly checked on every hour and, after R1 fell on March 1, 2020, R1 was put on 30-minute checks by staff. On March 2, 2020, prior to the fall and hospitalization, R1 was in their room with their spouse, had just been checked on by staff 10-15 minutes prior, was completely alert and did not exhibit any symptoms that would have indicated any fall risk. Then, on March 2, 2020 at about 10:25 a.m., R1 had an unwitnessed fall and, after being alerted be R1’s spouse, was found by staff on the floor of the bedroom bleeding from their head. R1 expressed that they had lost their balance, fell and hit their head. R1 appeared confused and disoriented, and also had a bump on their head. After R1 fell, staff had immediately responded to their room and called 911 to transport R1 to the hospital. Also, within the two (2) month period after admission, R1 had one fall and required occasional safety checks at the facility, per the care plan. A safety check log revealed that staff conducted safety checks in R1’s room at least once every hour prior to and until R1’s fall on March 2, 2020. R1 was not a fall risk prior to these incidents, and staff also followed R1’s care plan and properly responded to R1’s falls. The administrator expressed that R1 had lived at the facility for several months and, during this time, had a minor fall with no injuries, had been hospitalized once when R1 was not feeling well and a second hospitalization after the fall on March 2, 2020. After the latter fall, R1 was placed on 30-minute checks which were documented on a sheet inside of R1’s room.

A review of medical records dated March 2, 2020 to March 4, 2020 revealed that R1 was admitted to the hospital on March 2, 2020 with a small right parietal superficial laceration. A computerized tomography scan of R1’s head was negative and cervical spine was negative for fractures. There was also no evidence of acute intracranial hemorrhage, extra-axial collection, midline shift, herniation or hydrocephalus. A review of facility records revealed that R1 was admitted to the facility on December 23, 2019 with a diagnosis of hypertension and with the ability to ambulate independently with a walker. Facility records review also revealed that medication technicians had recently received a medication management in-service training. Also, the Department’s interviews with staff and facility records review, including an audit of R1's medication record, revealed that staff had administered R1’s medications according to physician’s orders.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam HamerTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20200309102027
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: 03/29/2021
NARRATIVE
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Based on the evidence obtained during the complaint investigation, including interviews and records review, the evidence does not support the allegations. The allegations are found to be UNSUBSTANTIATED, as there is not a preponderance of the evidence to prove that the allegations occurred.

An exit interview was conducted with Ms. Reyes, and a copy of this report along with Licensee's Rights (LIC 9058 01/16) were provided to her via the email address that she provided to LPA; an email read receipt confirms receipt of these rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam HamerTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3