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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004738
Report Date: 03/26/2021
Date Signed: 03/26/2021 05:23:21 PM

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:CANYON VILLASFACILITY NUMBER:
372004738
ADMINISTRATOR:RICHARD JOHN ROWEFACILITY TYPE:
740
ADDRESS:4282 BALBOA AVENUETELEPHONE:
(858) 273-1306
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:133CENSUS: 94DATE:
03/26/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Vonda Boller, Business DirectorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Laarni Santiago conducted a Case Management visit and contacted the facility via video conference, due to COVID-19. LPA identified herself and discussed the purpose of the call with Business Director, Vonda Boller.

In conjunction with complaint investigation, the following deficiencies, unrelated to the complaint were identified:

Department's investigation revealed that Resident 1 (R1 - see LIC811 Confidential Names List) required a two-person assist due to their health condition and limited mobility. Interviews conducted with facility staff and outside sources confirmed that R1 requires a two-person assist. A review of R1's facility records did not document that R1 requires a two-person assist. Facility failed to update R1's care plan to address the needs for a two-person assist.

A deficiency was cited in accordance to the California Code of Regulations, Title 22 and is on the attached 809-D.

An exit interview was conducted with Vonda Boller via video-call. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to Administrator via email. An electronic response confirms the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CANYON VILLAS
FACILITY NUMBER: 372004738
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2021
Section Cited

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The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by:
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Licensee failed to update R1's care plan to include the needs for a two-person assist. This poses a potential risk to resident 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 JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2021
LIC809 (FAS) - (06/04)
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