Coronado Retirement Village.

(Cont. from LIC 9099) Regarding the allegation that the facility is in disrepair, staff members and residents were interviewed. All interviews did not corroborate the allegations. Staff consistently stated that maintenance issues were documented in a designated binder, which maintenance staff reviewed each morning. They consistently reported that any issues are addressed promptly, including a common area bathroom door that was fixed shortly after it was reported that it was difficult to open. Residents consistently confirmed that they had no current maintenance concerns and that any past issues were resolved quickly. LPA reviewed the facility’s maintenance log and room inspection list dated June 2025. The checklist included room temperature, plumbing, wall heaters, call lights, grab bars, paint, lighting, and windows. Monthly inspections were conducted, though the time period for 2024 logs were unavailable. LPA observed clean, hazard-free hallways with fresh paint and intact walls. The reported common bathroom door opened freely, with no signs of disrepair. Resident rooms had accessible, functioning call lights. The Wellness Director demonstrated the call light system, which was verified by a staff member who correctly identified the room number. Regarding the allegation that the facility does not provide nutritious meals, staff interviews did not corroborate the allegation. Staff reported that resident complaints were primarily about the taste or flavor of the food, not its nutritional value. They consistently stated that alternative meals were available if residents did not want the main menu item(s). Staff also noted that the kitchen accommodated resident preferences and honored requests for different or additional food items. Resident interviews consistently reported satisfaction with the meals, stating that they liked the food, and received good portions of all food groups. One resident stated that while the food was generally acceptable, it was not always to their preference. They noted limited fruit options and occasional lack of protein, but also acknowledged dietary limitations due to dentures and stated that the food was “good enough.” (Cont. on LIC 9099-C pg. 2) 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 26 27 28 29 30 31 32 (Cont. from LIC 9099-C) LPA reviewed the facility’s food menus from the first and fourth weeks of August 2024, which included a variety of fruits, vegetables, and proteins such as green beans, seasonal fruit, sausage, turkey, and beef stroganoff. The menu for the second week of November 2025 was similar. An alternative menu offering items like burgers, sandwiches, vegetarian, and vegan options was also available. Meal times were scheduled for approximately an hour and a half. A review of the facility’s Sysco food purchase history from March 2025 showed consistent orders across all food groups. LPA observed tray service being delivered to resident rooms by the head cook and kitchen staff. LPA observed facility dining area with residents being served pizza, salads, soups, sides of yogurt, seasonal fruit, and beverages. LPA observed the facility menu of the day with numerous alternative foods which consisted of all food groups. Regarding the allegation that staff did not respond to resident's call button timely, staff consistently reported that a designated personal care assistant handled call buttons, and that additionally, staff supported one another to ensure timely responses. They stated they aimed to respond within 7–10 minutes, often responding sooner. Residents confirmed their call lights were functional and that staff responded promptly. LPA reviewed the call button log for the week of 11/10/2025, which showed an average response time of 3 minutes and 33 seconds. The facility stated logs could only be retrieved for the past three months. LPA also reviewed the facility’s call light policy, which required responses within 3–7 minutes. Calls exceeding 7 minutes triggered a self-check by the receptionist, and unresolved calls over 10 minutes prompted investigation and possible disciplinary action. (Cont. on LIC 9099-C pg.3) 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 26 27 28 29 30 31 32 (Cont. from LIC 9099-C pg. 2) LPA observed call lights in resident rooms and bathrooms, all hanging and accessible. The Wellness Director demonstrated the system, and a staff member correctly identified the room number in use, confirming functionality. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Wellness Director Camille Nero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.

The facility allowed R1 to return after discharge from the hospital. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Wellness Director, Camille Nero whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1].

Staff interviews confirmed they conducted status checks on R1. However, R1 was independent and did not like staff entering their room. Staff explained they would stand at the door and ask R1 is they were okay and/or needed anything. Staff stated R1 would respond no, and they would initial the check-in log and depart. Staff added R1 usually was in bed or sitting in their chair reading, and they would call out to R1 to check on them. R1 confirmed they did not like staff checking in on them and would refuse services. R1 also stated they tried to hide their injuries from staff by hiding their face during their check-ins and leaving the facility without stopping by the front desk to check out. R1 continued to report to staff they were fine, when checked on. A review of facility records verified the room checks conducted by staff were also supported by room check logs initialed by staff. The facility’s check-in log sheet for May 11, 2025, reflected R1 was checked on and staff confirmed R1 did not complain of pain or show signs of symptoms. R1 admitted they were able to hide their injuries and avoid staff. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Wellness Director, Camille Nero whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]

Staff interviewed confirmed that R1 was not found with the pillow over R1’s face but to the side of R1’s face, very close, but not to interfere with R1’s breathing. There are no corroborating statements or evidence to support the allegation. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were emailed to Executive Director, Rajni Kharbanda .

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA met with Executive Director, Rajni Kharbanda and Maintenance Manager, Luis Ibarra-Medina. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured between 108 - 110F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the Executive Director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An advisory note was issued regarding Personal Rights documentation. An exit interview was conducted with Executive Director to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

(Continued from LIC9099 Page 1) This was communicated to all involved parties, including R1's responsible party upon admission. R1 had twenty-four hour private caregivers (PC) and it was agreed upon that they would be responsible to administer medications with parameters. Staff informed that the accuracy of medications and timings were difficult due to Medical Technicians (MTs) needing to confirm what medications had been given each day. In addition, staff were informed by R1's physician that the PCs were to administer blood pressure medications. Staff informed that while the medication administration system caused confusion, no medication errors occurred with this resident based on the agreement. Staff informed that medications with parameters were locked inside R1's room and the MTs did not have access to R1's parameter medications at all times. An outside medical provider familiar with R1 (OS1) revealed that the facility would not be allowed to administer parameter medications without the help of a RN or another medical professional allowed to make medical decisions for residents. This was explained in full in a meeting between R1's family, the Executive Director of the facility, and OS1. It was determined that the PCs would have to administer parameter medications. Records Review revealed that on the Physician Communication & Progress Form, Dated 03/04/25: "[Power of attorney] POA doesn't want to discontinue parameters for Chlortalidone 25mg", "Chlortalidone to be given by caregiver." A review of the Medication Administration Record (MAR), Dated March, 2025 revealed: "Lisinopril: suspended 26 February 2025 to 31st March 2025: ON HOLD, Resident is on another BP Med with parameters private caregiver administering." A number of medications were not administered during the required prescription time, however each of those times had reasonable explanations such as: "Waiting for pharmacy to refill," "Withheld per DR/RN orders," "Given to family to give later", and "physically unable to take." The MAR did not indicate any medication errors or unexplained missing administrations. Regarding the allegation, "Licensee did not follow resident's care plan.", it was alleged that blood pressure checks were a part of the agreed upon care plan to which the facility was not consistently performing. Staff interviews revealed the process of admitting new residents and developing a care plan which did not include BP checks. The facility's New Admissions Care Plan can include but is not limited to: Oxygen order, LIC602, diet modifications, POLST, pharmacy information, etc. Staff informed that R1's care plan did not say that Blood Pressure (BP) checks were required. Staff informed that the care plan was made based on what R1's care needs were when they were first assessed by the facility and R1's Physician. Staff were to follow the care plan as directed whether the PC was there or not. (Continued on LIC9099 Page 3) 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 26 27 28 29 30 31 32 (Continued from LIC9099 Page 2) Outside Source Interviews revealed no concerns for the facility's ability to follow R1's agreed upon care plan. Coronado Retirement Village Resident Assessment & Care Plan/ Functional Capabilities, Dated 2/17/25 stated that R1 had as part of their main diagnosis HTN (Hypertension). HTN was a recorded condition of R1 during the admission process. Review of the Coronado Retirement Village New Admission Care Plan, Dated 2/17/2025 revealed no mention of Blood Pressure checks required in the care plan which corroborates staff statements. Regarding the allegation, "Licensee did not provide services agreed upon in the admissions agreement.", it was alleged that meal and tray services were not received by R1. Staff interviews revealed that R1 was never charged for the agreed upon tray service in the admissions packet and this was documented and removed from the final bill. Staff informed that the responsible party wanted R1 to eat in their room; however R1 was often away from the facility with PC during the day. Due to this arrangement, the pattern was inconsistent of when staff were to conduct tray service. R1's family gave their Sixty (60)-day notice and terminated their lease. Upon receiving the notice, the facility removed all charges that were not basic rent. Staff informed that R1's family was charged basic rent for April and May sans tray service. On the 11th of March, R1 moved out and the rent was totaled and prorated as final billing. Records review revealed on the Customer Payment History from 02/04/2025 - 05/01/2025: "February, March, and May are prorated; April, rent only. Prorated to exclude tray services and meal tickets. This corroborates staff statements. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are all UNSUBSTANTIATED. An exit interview was conducted with Wellness Director Camille Nero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from 9099) Staff interviews did not indicate that medications were not being given to residents as prescribed. All resident interviews and those with outside sources corroborated that they received their medications in a timely manner. An attempt for a copy of the Medication Administration Record (MAR) was done, however the facility switched over to a new recording system and are not obligated to retain records after three (3) years. All staff interviews acknowledge issues with being short staffed, but most do not believe it directly caused resident needs to go unmet. Resident interviews revealed that their needs were being met. File reviews of documents from May 2021 indicate that the average wait time for a call button response was 4 minutes and 39 seconds, facility census was 48 residents, and an average of 4-6 staff members were scheduled per shift. Interviews with residents, outside sources, and file reviews revealed that the admissions agreement was followed by the Administrator. Concerns discussed in interviews were explicitly listed as excluded responsibilities by the facility as per the Admissions Agreement. Staff interviews indicate that staff do receive adequate training. Staff were able to recall specific trainings completed, and the thoroughness of the staff training logs when conducting file reviews corroborated that. Furthermore, interviews with residents and their responsible parties did not reveal any concerns about staff being properly trained. Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. 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. Their signature below confirms receipt of these documents.

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Elizabeth Najera . According to the facility’s license, the facility has a maximum capacity of (120) residents, seven (7) of whom may bedridden. During today’s inspection, there were a total of eighty-four (84) residents in care. This facility features a delayed egress for dementia residents. LPA, accompanied by Najera, toured the interior and exterior of the facility, and inspected residents' rooms. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least seven (7) days of non-perishable food was present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per Najera , no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Confidential records were stored in locked area. Najera also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Najera, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA), Daniel Pena conducted a Case Management - Incident visit at the Coronado Retirement Village (CRV). LPA met with Administrator, Elizabeth Najera, after identifying himself and providing the purpose of the visit. On May 28, 2024, Community Care Licensing Division (CCLD) received a self-reported Death Report, involving the death of Resident #1 (R1). During the visit, LPA conducted interviews with CRV staff and obtained copies of pertinent facility and resident records. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Najera, whose signature below confirms receipt of these rights.

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.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Elizabeth Najera. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/05/2024). According to the LIC624, during the early morning of 02/01/2024, Resident #1 (R1) had an unwitnessed fall. [See LIC 811 Confidential Names List for a description of R1.] Staff observed R1 on the floor and was assessing them for injuries when R1 had a seizure episode. 911 was called and R1 was hospitalized. During today’s visit, LPA performed a brief facility tour. As of the date of LPA’s visit, R1 had not yet returned to the facility. LPA collected copies of and reviewed pertinent care records. LPA also interviewed relevant staff. No deficiencies were cited during today's visit. LPA issued one (1) Technical Violation (TV) regarding reporting requirements (see LIC9102-TV). LPA also issued Technical Assistance (TA) regarding medical assessment and reappraisal (see LIC9102-TA). An exit interview was conducted with Reyes, to whom a copy of this report, the LIC9102-TV, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Administrator further stated that the Licensee advised her on approximately September 2023 that she would compile all of R1's facility records and the Licensee would be in charge of sending out any facility records request for R1. Licensee stated that on September 23, 2023 they received a subpoena from R1's authorized representative to send them "all of the documents." On September 28, 2023 Licensee emailed the facility records to the authorized representative. On December 27, 2023 an employee of the authorized representative called the licensee and stated that they were missing some of the resident's documents from January 1, 2022 through December 23, 2023. Licensee stated that they would resend the requested attachments to the authorized representative. LPA records review revealed that a declaration of custodian of records was signed and dated on September 28, 2023 by the Licensee. Records review further revealed that over 400 pages of resident records were emailed to the authorized representative on September 28, 2023. The records emailed spanned from 2021 through 2023 and included; resident assessment and care plans, admission agreement, physicians reports, medication orders, incident reports, hospital discharge forms, medication refill orders and professional communication notes, etc. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Liz Najera. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Liz Najera whose signature below verifies receipt of these rights.

Closed-circuit television system evidence was reviewed as part of this investigation. On the day of the incident, there was one staff member in the dining room supervising four residents. R1 was talking to another resident while R2 was standing on the other side of the room. R1 left talking to the resident and casually walked toward R2. The security video is blurry, but it appears that R1 tried to grab R2 by the arms and R2 pushed R1 away in a startled or defensive move. R1 fell to the ground. Caregiver 1 (CG1) responded immediately and called for assistance on their handheld radio. Medication Technician (MT1) responded to the call for assistance. MT1 assessed R1 for injuries and called 911 to have R1 transported to the hospital to be evaluated. According to CG1, they did not see the incident between R1 and R2 that caused R1 to fall. CG1 did not hear the conversation or any argument between them. Video review showed, R1 casually walked toward R2 without obvious signs that R1 was upset and an altercation between R1 and R2 was imminent. In fact, the video shows that R1 approached R2 and R2 was most likely defending himself from R1. Based on the Department’s investigation, the allegation of Neglect/lack of supervision and care resulted in physical abuse of a resident by another resident, resulting in serious injury is Unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Office Manager, Avalos, whose signature below confirms receipt of these rights.

reflect R1 was or reported being assaulted. The alleged incident occurred in the CRV Memory Care Unit. A sample of Memory Care Unit residents were interviewed but due to their medical/physical conditions could not serve as qualifiable witnesses. In their interview, R1 said they were in bed and were asleep when "a man hit me." R1 did not know who the man was. R1 never saw the person before. R1 said the man struck them in the forehead once. R1 told a family member but did not report the incident to CRV employees. R1 said they were seen by a doctor but received no injury. R1 has not seen the man again. When asked, R1 said they felt safe at CRV. When asked, R1 said no CRV staff or another resident hit them. R1 said there was no witness to the incident. Staff interviews yielded no conclusive evidence to support the allegation. Staff generally said they were familiar with R1 and knew they had Dementia. None of the staff witnessed any person strike R1 at any time. Interviews with outside sources did not produce information to corroborate the allegation. LPA observation during a walk through of the facility did not show evidence that R1 had been assaulted. A law enforcement officer responded to the facility, but no arrest was made. The Department has investigated the allegation that a resident was hit by an unknown adult while in care, resulting in injury. Based on interviews and record reviews the investigation failed to produce sufficient evidence to support the allegation. The preponderance of evidence standard was not met; therefore, the allegation is deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Office Manager, Avalos, whose signature below confirms receipt of these rights.

[Continued from LIC9099] During investigation, LPA Domingo collected pertinent resident records as well as facility documentation. Based on Resident1’s (R1) (See LIC811 list of confidential list of identification)Physician Report dated January 11, 2023 revealed that Resident 1 (R1)  does not have cognitive deficits.  R1 is able to verbalize any needs or concerns. R1 is able to state who is to visit and not to visit. Allegations received stated that R1 was not accorded privacy . According to Outside Source 1 (OS1), R1 verbalized wanting facility staff to be present during visits.  Outside source 2 (OS2) also concurred and verified that R1 has requested a staff member to be present during visitations. Outside Source 3 (OS3) wrote a statement that also verified that R1 verbally stated that visitations are to be supervised. Allegation stated that R1’s medication was not given as prescribed. Records reviewed showed no evidence of medication not given as prescribed.  O3 was interviewed and stated that R1's medication was properly given.  O2 was interviewed and R1's medication was given as prescribed.  Staff 1 (S1) reviewed records of R1's medication and there was no evidence of medication not given as prescribed. Allegation stated that untrained staff provided catheter care for R1. Interview with Staff 2 (S2) revealed that R1's catheter was being cared for by a trained staff member.  Records reviewed revealed that R1 was taken to the hospital as needed when there was a medical need regarding R1's catheter care. Outside Source 4 (OS4) was interviewed and corroborated with R1's record review. Allegation stated that facility staff did not obtain medical attention for resident. OS4 was interviewed and there were no instances of staff not obtaining medical attention for R1. S1 was interviewed and R1's medical needs were being met. Records reviewed documented R1's medical needs were being met by the facility staff. [Continue on LIC9099] 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 26 27 28 29 30 31 32 [Continued from LIC9099] Lastly, it was alleged that facility staff did not notify responsible party of changes in resident condition.  Records reviewed documented communication with responsible party of all changes related to R1.  OS1 was interviewed and verified that any changes were communicated.  LPA Domingo reviewed records that collaborated any changes with R1 was communicated. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated . An exit interview was conducted with Administrator  Elizabeth Najera, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.