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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604490
Report Date: 02/16/2023
Date Signed: 02/17/2023 10:33:03 AM

Document Has Been Signed on 02/17/2023 10:33 AM - It Cannot Be Edited

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:COLLEGE TOWN SENIOR RETIREMENT VILLA INCFACILITY NUMBER:
374604490
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:5252 STONE CTTELEPHONE:
(619) 432-1236
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 6CENSUS: 6DATE:
02/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Caregiver Nvard BedekyanTIME COMPLETED:
05:13 PM
NARRATIVE
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Licensing Program Analyst (LPA) Debbie Correia conducted a case management visit regarding a violation identified while at the facility for an unrelated visit conducted on January 25, 2023. LPA gained access to the facility and met with Caregiver Nvard Bedekyan to whom was explained the purpose of the visit.

During the visit, LPA Correia observed one (1) staff member without a mask on, and one (1) staff member wearing a mask pulled below their nose while around residents in care. The facility is being cited during today's visit due facility staff not following infection control guidelines regarding staff use of facial coverings while working with residents in care during the January 25, 2023 visit.

An exit interview was conducted with Caregiver Nvard Bedekyan. A copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided to the facility at the conclusion of the visit. The signature below confirms receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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Document Has Been Signed on 02/17/2023 10:33 AM - It Cannot Be Edited


Created By: Debbie Correia On 02/10/2023 at 08:42 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: COLLEGE TOWN SENIOR RETIREMENT VILLA INC
FACILITY NUMBER: 374604490

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited
CCR
87468.1(a)(2)

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Personal Rights of Residents in All Facilities. Residents in...care facilities for the elderly shall have... the following personal rights. To be accorded safe, healthful and comfortable ...furnishings and equipment.

This This requirement was not met as evidence by:
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Licensee Petrosyan agreed to have facility staff review current COVID-19 guidance per PIN dated 23-02-ASC. Licensee and facility staff will also attend an on-line CDSS approved course on infection control guidance.
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Based on LPA observations on 01/25/2023, the Licensee did not ensure facility staff were in compliance with the proper use of masks while working with residents in care. This posed a potential health risk to 6 out of 6 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.
SUPERVISOR'S NAME:Simon Jacob
LICENSING EVALUATOR NAME:Debbie Correia
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
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