374603136-11-24-2025-08-AS-LTEZ-DPU3X6-20251229173750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603136
Report Date: 11/24/2025
Date Signed: 11/24/2025 02:11:33 PM

Unsubstantiated

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
08/19/2024 and conducted by Evaluator Janet Ngallo

COMPLAINT CONTROL NUMBER: 08-AS-20240819155540

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: 83	DATE:	11/24/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Wellness Director Camille Nero		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility in disrepair.
Facility does not provide nutritiuous meals.
Staff did not respond to resident's call button timely.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above mentioned complaint allegations. LPA introduced themselves to and disclosed the purpose of the visit to Wellness Director Camille Nero.

On 08/19/2024, it was alleged that the facility was in disrepair, does not provide nutritious meals, and that staff did not respond to resident's call button timely. The Department’s investigation consisted of unannounced facility visits, LPA observations, interviews with residents and facility staff, and records review.

(Cont. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

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 4

Control Number 08-AS-20240819155540

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: 11/24/2025

NARRATIVE

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(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)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20240819155540

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: 11/24/2025

NARRATIVE

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(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)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20240819155540

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: 11/24/2025

NARRATIVE

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(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.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

LIC9099 (FAS) - (06/04)

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