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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600890
Report Date: 10/16/2025
Date Signed: 10/16/2025 03:07:26 PM

Document Has Been Signed on 10/16/2025 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ATRIA COLLWOODFACILITY NUMBER:
374600890
ADMINISTRATOR/
DIRECTOR:		JULIA LOPEZFACILITY TYPE:
740
ADDRESS:5308 MONROE AVETELEPHONE:
(619) 286-3583
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 185CENSUS: 98DATE:
10/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Engage Life Director Naomie Peterson and Resident Services Director Ashley Baino-Jaimes, LVNTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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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 Engage Life Director Naomie Peterson. LPA also met briefly with Resident Services Director Ashley Baino-Jaimes, LVN.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/13/2025). According to the LIC624, on 10/13/2025, Resident #1 (R1) eloped from the facility (left without staff supervision), walking to a nearby grocery store to buy beer. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] Facility staff located R1 around 1 to 2 hours later and brought them back to the facility, unharmed.

During today’s visit, LPA performed a brief facility tour and welfare check and interview of R1, verifying that they were safe and uninjured from the incident. LPA interviewed multiple pertinent managers and frontline staff and collected relevant care records on R1.

According to their LIC602 Physician’s Report, R1’s diagnoses included Mild Cognitive Impairment (MCI), and their doctor had determined that R1 was not safe to leave the facility unassisted. The Needs and Services Plan (Care Plan) which Licensee authored reiterated, “[R1] must be supervised when leaving the community.”


[CONTINUED ON LIC 809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ATRIA COLLWOOD
FACILITY NUMBER: 374600890
VISIT DATE: 10/16/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

Records and interview showed: Prior to 10/13/2025, R1 had no prior elopements or elopement attempts, and did not exhibit agitation, wandering, or exit-seeking behaviors. On 10/13/2025, facility receptionist Staff #1 (S1) last saw R1 enter the facility's first floor public restroom around 3:00 PM. R1 was calm at that time; R1 did not say anything to S1 about wanting to go to the store or wanting to leave the facility. Around 4:00 PM, caregiver Staff #2 (S2) went to R1’s bedroom to escort them to dinner in the dining room. Upon finding R1 and their walker absent from their bedroom, S2 alerted teammates. Facility managers placed timely phone calls to R1’s responsible person (RP) and physician/hospice personnel, to notify them of the problem. A dining room waitstaff/server Staff #3 (S3) quickly came forward to report that sometime earlier around 3:10 PM, they had personally observed R1 on the sidewalk outside the facility, walking up a hill and near a crosswalk that was less than 100 yards from the facility. (However, S3 at that time did not recognize this as a safety problem and did not notify their teammates; S3 was unsure whether R1 was allowed to leave the facility unassisted.) Two (2) facility managers thus got into cars and traveled in that general direction, locating R1 in a grocery store parking lot around 4:45 PM. R1 was unharmed, and given a ride back to the facility. Per LPA’s interview of R1, although they were somewhat forgetful, R1 confirmed on the date in question, they walked went to the store to buy beer, and that they exited the facility via the lobby front door.

During today’s visit, LPA observed/evaluated the layout of the facility’s lobby from different angles, with a focus on where the receptionists’ chair at the front desk is positioned in relation to the facility’s front door. LPA observed that the receptionist’s line of sight, from their chair to the front door, is currently partially impeded, due to the chair not being well-aligned with the front door. It was therefore possible for a resident to exit the common area “activity room” and reach the front door, all without the receptionist seeing them. LPA observed that by slightly rearranging items on the existing front desk (without changing out or moving the desk), it would be possible to slide the receptionists’ chair over by one (1) foot and thus give them full view of the lobby front door, from where they sit. LPA queried two (2) receptionists, who agreed such an arrangement could comfortably work for them. [This will be part of Licensee’s Plan of Correction.]


[CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ATRIA COLLWOOD
FACILITY NUMBER: 374600890
VISIT DATE: 10/16/2025
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

CCLD’s investigation concluded: Licensee had an Absentee Notification Plan for R1, as required, and essentially followed it during this incident. However, R1 was able to leave the facility without S1 observing/noticing, which represents a temporary lapse in supervision. S3 saw R1 outside the facility but did not immediately recognize this as a safety risk, which represents a lapse in competency/training. CCR 87468.2(a)(4) guarantees residents’ right to care and supervision that “meet their individual needs and are delivered by staff that are sufficient…in competency to meet their needs.” One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Engage Life Director Naomie Peterson, to whom a copy of this report, the LIC809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/16/2025 03:07 PM - It Cannot Be Edited


Created By: Dang Nguyen On 10/16/2025 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA COLLWOOD
FACILITY NUMBER: 374600890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2025
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in…competency to meet their needs.” This requirement was not met, as evidenced by:
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On 10/14/2025, Licensee performed an elopement drill and training for staff. Licensee agreed to: a) Rearrange the layout of the facility’s front desk, such that the receptionists can sit fully to the far left edge of the desk, with an unobstructed view of the lobby front door; b) Add resident photographs to the existing document/list of residents who are not able to safely leave the facility unassisted; and c) Post or make this document readily viewable to staff in each division/department (i.e., reception, med room, care office, activity office, maintenance office, etc.). Licensee agreed to photograph (a) through (c), and to send proof of completion to LPA, by the POC due date.
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Based on records and interviews, Licensee did not ensure that 1 of 98 residents (R1) had the care and supervision needed to meet their individual needs. This posed a potential safety risk to persons in care.
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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
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