Coronado Retirement Village

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee attempted unlawful eviction/discharge of resident

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 attempted unlawful eviction/discharge of resident. It was reported Resident #1 (R1) was not allowed to return to the facility once discharged from the hospital. On 10/03/25, R1 was trasported to the hospital due to an order written by R1's physician requiring a psyche evaluation. However, R1 was taken to the incorrect hospital for the evaluation and was discharged and returned the same day to the facility. The Wellness Director explained there was a miscommunication with the hospital but R1 was allowed to return. R1 returned to the facility and went to their room. The Executive Director documented a letter dated 09/09/25 to R1 indicating R1'sthe state’s words, verbatim · CDSS document, Oct 14, 2025 · control 08-AS-20251006121233

Allegation investigated: Facility staff did not meet resident's care needs

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 the facility staff did not meet resident's care needs regarding Resident #1 (R1). It was reported that on May 5, 2025, R1 fell at the facility, sustained injuries, and did not report the incident to facility staff. R1’s Physician’s Report dated July 18, 2024, indicated R1 was ambulatory and independent with bathing, dressing/grooming, feeding, toileting, medication management, laundry and able to leave the facility unassisted. On May 7, 2025, R1 was observed by staff with a bump the size of a quarter on R1’s forehead and a black eye. An outside source reported staff never saw the injury when it occurred due to not properly checking on R1. The outside source althe state’s words, verbatim · CDSS document, Sep 26, 2025 · control 08-AS-20250610103152

Allegation investigated: Licensee did not seek medical care for resident

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 09/26/2the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 08-AS-20250626090416

Allegation investigated: Staff did not accord resident safe accommodations

Licensing Program Analyst (LPA), Natasha Persaud contacted the facility via telephone, to conclude the complaint investigation regarding the above-mentioned allegation. LPA spoke with Executive Director, Rajni Kharbanda. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that staff did not accord resident safe accommodation. It was reported that on 06/08/25, Resident #1 (R1) was lying on their bed fully clothed with shoes on and a pillow over their face. R1 had a medical condition that required medical attention. Staff called 911 and R1 was transported to the hospital. R1 also has a Major Neurocognitive Disorder and didn’t recall the incident, when interviewed. R1 confirmed they sleep in their bed, on top of their covers, fully clothed, and wearing shoes. R1 also confirmed they do not sleep with a pillow over their face or feel they are in harm. Continued on an LIC 9099C. Unsubthe state’s words, verbatim · CDSS document, Sep 2, 2025 · control 08-AS-20250609134506

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee did not administer medications as prescribed. Licensee did not follow resident's care plan. Licensee did not provide services agreed upon in the admissions agreement.

Licensing Program Analysts (LPAs) Ramin Hashemi, Nacole Patterson and Janet Ngallo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPAs introduced themselves and disclosed the purpose of the visit to Wellness Director Camille Nero. On 03/17/2025 it was alleged Licensee did not administer medications as prescribed, Licensee did not follow resident's care plan, and Licensee did not provide services agreed upon in the admissions agreement. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Licensee did not administer medications as prescribed", it was alleged that multiple medication administrations were missed for Resident 1 (R1). Staff interviews revealed the medication in question was tied to a vitals parameter which the facility could not administer without a twenty-four hour nurse. (Continued on LIC9099 Page 2)the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 08-AS-20250317093152

Allegation investigated: Staff are not safeguarding resident's personal possessions

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegation. LPA met with Wellness Director, Camille Nero. Executive Director, Rajni Kharbanda arrived during the visit. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, resident, and outside sources. It was alleged staff are not safeguarding resident's personal possessions. It was reported Resident #1 (R1) was missing $150 dollars in April 2025. Staff were interviewed and denied taking R1's money and were not aware of what happened to R1's money. Staff also stated R1 does not leave the facility unless transported by their PACE program. Therefore, they were not aware R1 withdrawled cash as they are not responsible for R1's cash resources. A review of the Resident Property and Values sheet dated 04/17/24, did not indicate $150 dollars was to be safeguarded by the facility. R1'the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 08-AS-20250408110439

Allegation investigated: Staff did not give medication as prescribed

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegation. LPA met with Wellness Director, Camille Nero. Executive Director, Rajni Kharbanda arrived during the visit. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, resident, and outside sources. It was alleged staff did not give medication as prescribed. It was reported Resident #1 (R1) had a PRN order on file for Desitin paste to be applied for skin irritation. Outside source #1's (OS1) interview revealed on 04/15/25, R1 complained of pain twice in the same day and the Desitin was brought to R1 but not applied. An interview with a Medication Technician (med tech) stated only the med tech's are allowed to administer the cream. Another med tech stated that the med tech dispenses the cream into a cup and the caregivers apply the cream. Staff interviews revealed conflictinthe state’s words, verbatim · CDSS document, Jul 15, 2025 · control 08-AS-20250418130533

Allegation investigated: Staff did not give medications as prescribed Due to insufficient staff, residents’ needs are not being met Licensee did not abide by admissions agreement Staff are not properly trained

Licensing Program Analysts (LPA) Arian Golbakhsh and Amy Rodgers conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPAs were welcomed by, identified themselves to, and discussed the purpose of their visit with Administrator Elizabeth Najera. On 05/18/2021, it was alleged that staff did not give medications as prescribed, residents’ needs were not being met due to insufficient staff, Licensee did not abide by admissions agreement, and staff are not properly trained. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with staff, residents, and outside sources. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 20, 2024 · control 08-AS-20210518135552

Allegation investigated: Facility was unsanitary.

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced visit in response to the above-mentioned allegation to deliver an amended report. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Elizabeth Najera. It was alleged that the facility was unsanitary. The Department's investigation consisted of LPA observations, record review, and interviews with staff, residents, and outside sources. LPA observed a housekeeper cleaning a lobby restroom. Resident rooms were clean and hallways, elevator, dining room, and resident rooms were sanitary and in order. Staff, residents, and outside sources interviewed said the facility is clean. Outside sources preferred to use their loved one's restroom. LPA reviewed housecleaning schedules and staffing levels were sufficient. Completed tasks were signed off on a daily checklist. According to records and interviews there is insufficient evidence that the alleged violation occurred. Therthe state’s words, verbatim · CDSS document, Dec 20, 2024 · control 08-AS-20241218165603

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff dropped resident resulting in multiple fractures. Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced complaint visit at the facility to close out a complaint. LPA gained access to the facility and met with Administrator, Liz Najera, and explained the purpose of the visit which was to deliver findings for the above allegations. The Department’s investigation consisted of record reviews, interviews with staff, residents and outside sources. It was alleged that staff dropped resident resulting in multiple fractures. Interviews revealed that on July 23, 2020, on or about 1:00 PM Staff 1 (S1) indicated they were transferring Resident 1 (R1) from the wheelchair to their bed by themself. R1 became combative and S1 believed they were going to lose control of R1, so S1 assisted R1 to the floor. Interviews revealed R1 slid between S1’s legs and R1’s legs twisted as they slid. S1 conducted a body check and observed a skin tear with blood on their left knee and during the check, R1 complained of left knee pain. A review of ththe state’s words, verbatim · CDSS document, Mar 12, 2024 · control 08-AS-20200807104355

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not provide resident records to resident's authorized representative

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Administrator Liz Najera and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of records review, interviews with facility staff and outside sources. It was alleged that staff did not provide resident records to resident's authorized representative It was reported to CCL that as of December 13, 2023 no facility records have been produced for Resident 1 (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) Interview with Administrator revealed they have been in frequent contact with R1's responsible party as well as R1's authorized representative for many months. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 25, 2024 · control 08-AS-20231227093312

Allegation investigated: Lack of supervision resulted in resident physical abuse by another resident which resulted in serious injury

On 1/5/2024, at about 8:20 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to conclude a complaint investigation. LPA identified himself and discussed the allegations mentioned above with Erika Avalos, Office Manager. On 06/27/2023, the Department received a complaint, alleging lack of supervision resulted in resident physical abuse by another resident which resulted in serious injury. The Department’s investigation consisted of LPA observation, record reviews, and interviews with residents, staff, and outside sources. Resident 1 (R1) and Resident 2 (R2) were both admitted to Memory Care, have a diagnosis of dementia and suffer from severe cognitive impairment. Both residents have shown signs of aggression toward staff and or other residents, but the last documented incident occurred in March of 2023 when R1 punched a staff member and attempted to hit several residents. Both R1 and R2 had medication changes or increases to calm them and make them less aggthe state’s words, verbatim · CDSS document, Jan 5, 2024 · control 08-AS-20230627133539

Allegation investigated: Resident hit by unknown adult while in care, resulting in injury

On 12/7/2023, at about 8:55 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to conclude a complaint investigation. LPA identified himself and discussed the allegations mentioned above with Erika Avalos, Office Manager. On 6/29/2022, the Department received a complaint, alleging a resident was hit by an unknown adult while in care, resulting in injury. The Department’s investigation consisted of LPA observation, record reviews, and interviews with residents, staff and outside sources. Record reviews showed that the incident was reported by facility staff as an unwitnessed fall. Resident 1 (R1)’s records showed that they have Mild Cognitive Impairment (MCI), history of falls, and visual impairment. The facility records indicate staff reported an incident involving this resident on 6/22/22 where the resident experienced an unwitnessed fall. The resident was transported to the hospital where they were diagnosed with a bruise to the forehead. None of the recorthe state’s words, verbatim · CDSS document, Dec 7, 2023 · control 08-AS-20220629133454

Allegation investigated: Resident was denied visitors Resident was not accorded privacy Medication not given as prescribed Untrained staff provided catheter care Facility staff did not obtain medical attention for resident Facility staff did not notify POA of changes in resident's condition.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings in the above complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Administrator Elizabeth Najera. On June 29, 2023 Community Care Licensing (CCL) received a complaint alleging resident was denied visitors, resident was not accorded privacy, medication not given as prescribed, untrained staff provided catheter care, Facility staff did not obtain medical attention for resident and Facility staff did not notify POA of changes in resident's condition. [Continued on LIC9099C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 26, 2023 · control 08-AS-20230629135237