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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603136
Report Date: 09/26/2025
Date Signed: 10/03/2025 09:40:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/26/2025 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20250626090416
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: 79DATE:
09/26/2025
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Wellness Director, Camille NeroTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Licensee did not seek medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above-mentioned allegation(s). LPA met with Wellness Director, Camille Nero.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that the licensee did not seek medical care for a resident. Resident #1 (R1) fell on May 5, 2025, and sustained a bump/cut on their forehead, and a right black eye. R1’s Physician’s Report dated July 18, 2024, indicated R1 was ambulatory and independent with bathing, dressing/grooming, feeding, toileting, medication management and able to leave the facility unassisted.

R1’s interview confirmed they fell while walking to the bathroom at nighttime and slipped on some magazines in their room. R1 reported they fell to the ground striking their head against their bed frame. Continued on LIC 9099C. This is an amended version of the original report created on 09/26/25.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
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 6
Control Number 08-AS-20250626090416
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CORONADO RETIREMENT VILLAGE
FACILITY NUMBER: 374603136
VISIT DATE: 09/26/2025
NARRATIVE
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R1 also reported they cleaned themselves up and changed their clothing after the fall and did not call for assistance. Staff interviews confirmed on May 6, 2025, R1’s room was cleaned, and blood was observed by staff on R1’s bed sheets. Staff also confirmed R1 reported to them on May 6, 2025, that R1 suffered a fall the previous day and were experiencing back pain. Facility staff are trained to notify administrators or the on-duty med-tech if a resident complains of pain. However, the staff did not report the incident causing R1 to suffer undo pain until R1’s injuries were discovered the following day May 7, 2025, around 12:00 PM, by another staff member. The administrator stated that R1’s room was normally dark, and that staff will normally enter the room and check on R1 from the doorway because R1 does not want or like being checked by staff. The room checks conducted by staff were initialed by staff on May 5, 2025, and May 6, 2025, Staff confirmed R1 does not like it when staff come into their room and check on R1. Therefore, staff will open the door and either observe R1 in bed or on their couch. Staff explained they will stand in the doorway and call out to R1 and ask if R1 is okay. R1 would always respond by saying they are okay and do not need anything. Staff added R1 always keep their lights off and curtains closed so it is dark in the room and hard to see. Once R1 reported to staff they were not well, the facility did not seek medical treatment until the following day resulting in delayed medical care. The Wellness Director’s interview confirmed R1 had to be transported to the hospital due to R1 suffering a head injury, as that was the facility’s procedure.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. 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].
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20250626090416
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CORONADO RETIREMENT VILLAGE
FACILITY NUMBER: 374603136
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
09/27/2025
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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The Wellness Director stated In-Service training will be conducted with staff to review contacting 911, emergency protocols, and chain of command. The Wellness Director will schedule the training by POC due date and provide proof of training within 2 weeks.
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This requirement is not met as evidenced by:
Based on interviews, the licensee did not contact 911 upon learning that 1 out of 74 [R1] residents fell and had complained of pain, which posed an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/26/2025 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20250626090416

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: 79DATE:
09/26/2025
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Wellness Director, Camille NeroTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Neglect resulted in serious injury
Neglect resulted in dehydration
Licensee did not report change of condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above-mentioned allegation(s). LPA met with Wellness Director, Camille Nero.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that neglect resulted in serious injury for Resident #1 (R1). R1 fell on 05/05/25 and sustained a bump/cut on their forehead, and a black eye. R1’s Physician’s Report dated 07/18/2024 indicated R1 was ambulatory and independent with bathing, dressing/grooming, feeding, toileting, medication management, and able to leave the facility unassisted. R1’s interview confirmed they fell while walking to the bathroom at nighttime and slipped on some magazines in their room. R1 also reported they cleaned themselves up and changed their clothing after the fall and did not call for assistance. R1 admitted at the time of the incident, they did not report the fall/injuries. Continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20250626090416
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CORONADO RETIREMENT VILLAGE
FACILITY NUMBER: 374603136
VISIT DATE: 09/26/2025
NARRATIVE
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Although R1 lived independently and did not require any assistance with their Activities of Daily Living, staff would do status checks on R1 in their room two times per shift. R1 corroborated with a staff statement stating staff checked on R1 often and offered to provide assistance, which R1 refused. R1 did not require line of sight supervision and was independent. Therefore, when R1 fell and did not report the incident, the injury was not due to neglect. The room checks conducted by staff were also supported by room check logs initialed by staff on 05/05/25 and 05/06/25. Staff confirmed R1 does not like when staff come into their room and check on R1. Therefore, staff will open the door and either observe R1 in bed or on the couch. Staff explained they will stand in the doorway and call out to R1 and ask if R1 is okay. R1 would always respond by saying they are okay and do not need anything. Staff added R1 liked to keep their lights off and curtains closed so it is dark in the room and hard to see.

It was also alleged that neglect resulted in dehydration. An outside source reported that R1 was not eating upon their return from their hospital visit on 05/07/25. The outside source also reported R1 was malnourished and dehydrated. R1 was seen at the hospital on 05/07/25 and returned to the facility the same day. R1 returned to the hospital on 05/11/25 due to the pain worsening and shortness of breath. R1 was discharged back to the facility on 05/16/25. R1’s medical records for hospital visits dated 05/07/25 and 05/11/25 were reviewed. There was no diagnosis or documentation of R1 being malnourished or dehydrated during R1’s examinations. R1’s interview indicated R1 did not like the food served at the facility and had a refrigerator in their room with a variety of food items. R1 indicated they go to the grocery store independently to purchase their food items. R1 reported they preferred to eat the food from their refrigerator and never felt they were not eating enough. R1 also stated that staff would offer R1 water, but R1 did not like water and would make themselves lemonade. R1 also reported they made a mistake telling the paramedics they hadn’t eaten in five days. R1 clarified that they meant they hadn’t been to the dining room to eat for five days. R1 denied not receiving enough to drink or eat. Staff reported they would ask R1 if they wanted staff to heat their food and R1 refused their help and said they would do it themselves. liked to keep their lights off and curtains closed so it is dark in the room and hard to see.

It was also alleged that neglect resulted in dehydration. An outside source reported that R1 was not eating upon their return from their hospital visit on 05/07/25. The outside source also reported R1 was malnourished and dehydrated. R1 was seen at the hospital on 05/07/25 and returned to the facility the same day. R1 returned to the hospital on 05/11/25 due to the pain worsening and shortness of breath. Continued on LIC 9099C.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20250626090416
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CORONADO RETIREMENT VILLAGE
FACILITY NUMBER: 374603136
VISIT DATE: 09/26/2025
NARRATIVE
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R1 was discharged back to the facility on 05/16/25. R1’s medical records for hospital visits dated 05/07/25 and 05/11/25 were reviewed. There was no diagnosis or documentation of R1 being malnourished or dehydrated during R1’s examinations. R1’s interview indicated R1 did not like the food served at the facility and had a refrigerator in their room with a variety of food items. R1 indicated they go to the grocery store independently to purchase their food items. R1 reported they preferred to eat the food from their refrigerator and never felt they were not eating enough. R1 also stated that staff would offer R1 water, but R1 did not like water and would make themselves lemonade. R1 also reported they made a mistake telling the paramedics they hadn’t eaten in five days. R1 clarified that they meant they hadn’t been to the dining room to eat for five days. R1 denied not receiving enough to drink or eat. Staff reported they would ask R1 if they wanted staff to heat their food and R1 refused their help and said they would do it themselves.

Lastly, it was alleged that the licensee did not report a change of condition for R1. On 05/07/25, R1 was transported to the hospital and diagnosed with a fractured rib. On 05/11/25, R1 complained of pain and shortness of breath to an outside source and was transported to the hospital. On 05/11/25, R1 was diagnosed with fractured ribs and Pneumonia. A review of R1’s medical reports indicated R1 had a history of Pneumonia. A review of the hospital’s final summary reflected that shortness of breath was more consistent with splinting and atelectasis in the setting of known rib fractures. The facility did not report a change in condition as there was no change in condition. R1’s shortness of breath may have been a result of the fractured ribs but was not documented as a change of condition.



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 allegations are 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]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6