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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603136
Report Date: 09/29/2021
Date Signed: 09/29/2021 04:00:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 64DATE:
09/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator Elizabeth ReyesTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow-up on an incident. LPA was greeted by, identified herself to, and explained the purpose of the visit to Administrator Elizabeth Reyes.

The facility self reported an incident regarding Resident 1 (R1) (See LIC811 Confidential Names List) on September 9, 2021.

During the visit, LPA reviewed and obtained copies of resident records. At this time the incident requires further investigation. No deficiencies were cited during today's visit.

An exit interview was conducted with Administrator Elizabeth Reyes, to whom a copy of this report and the Licensee's Rights (LIC9058 01/16) were provided via electronic mail.
SUPERVISOR'S NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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