374603136-6-3-2021-08-AS-SJAB-C4GQ97-20210630115749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603136
Report Date: 06/03/2021
Date Signed: 06/03/2021 01:39:08 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
05/24/2021 and conducted by Evaluator Laarni Santiago

COMPLAINT CONTROL NUMBER: 08-AS-20210524095403

FACILITY NAME:	CORONADO RETIREMENT VILLAGE		FACILITY NUMBER:	374603136
ADMINISTRATOR:	ELIZABETH REYES		FACILITY TYPE:	740
ADDRESS:	299 PROSPECT PLACE		TELEPHONE:	(619) 437-1777
CITY:	CORONADO	STATE: CA	ZIP CODE:	92118
CAPACITY:	120	CENSUS: 54	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Elizabeth Reyes, Administrator		TIME COMPLETED:	01:42 PM

ALLEGATION(S):

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Staff did not provide access to a resident's records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Laarni Santiago conducted an unannounced complaint investigation tele-visit via FaceTime due to COVID-19. LPA identified herself, spoke with Administrator, Elizabeth Reyes, and discussed the purpose of the visit, which was to deliver findings for the above allegation.

The Department’s investigation included interviews with Administrator, Executive Director (ED) and outside sources. Facility records were also obtained by the Department and reviewed for pertinent evidence.

The Department received a complaint on May 24th, 2021, alleging that the facility failed to provide resident records after a Legal representative served a subpoena to the facility. An interview with Administrator revealed that on May 18th, 2021, they received an e-mail regarding a subpoena for resident 1 (R1) (See LIC 811 Confidential Names List to verify R1). Administrator advised that it's protocol to forward all subpoenas to ED for review prior to responding. Supporting evidence revealed that Administrator forwarded the subpoena to ED on the same day it was received. ED instructed Administrator to follow-up and

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210524095403

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: 06/03/2021

NARRATIVE

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and ask which specific records are needed. On May 19th, 2021, Administrator contacted the outside source to ask which specific records are needed and were advised that they would get back to Administrator with that information. Based on interviews conducted with outside source, Administrator and records reviewed, there were no evidence to show that the outside source responded to the facility's request to verify which documents need to be submitted. Furthermore, evidence obtained from supporting documents revealed that on May 25th, 2021, Administrator conducted a follow-up email to the outside sources asking to verify which documents need to be submitted. Outside source admitted that they did not respond to Administrator's e-mail to verify which documents need to be submitted. Based on interviews and evidence obtained, there is insufficient evidence to suggest that the allegation is true.

The Department has investigated the allegation that the staff did not provide access to a resident's record. Based on evidence obtained, including interviews and records reviewed, the allegation is found to be unsubstantiated as the Department could not meet the preponderance of the standard evidence.

An exit interview was conducted with Administrator via and a copy of this report, confidential names list and Licensee/Appeals Rights (LIC 9058 01/16) was provided to Elizabeth via email. An electronic read receipt confirms receipt of documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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