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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004738
Report Date: 01/02/2025
Date Signed: 01/03/2025 09:10:04 AM

Document Has Been Signed on 01/03/2025 09:10 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CANYON VILLASFACILITY NUMBER:
372004738
ADMINISTRATOR/
DIRECTOR:
BOLLER, VONDAFACILITY TYPE:
740
ADDRESS:4282 BALBOA AVENUETELEPHONE:
(858) 273-1306
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 133TOTAL ENROLLED CHILDREN: 0CENSUS: 95DATE:
01/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Vonda BollerTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection visti. The LPA introduced himself and disclosed the purpose of the visit to Administrator Vonda Boller. The facility was licensed for a capacity of one hundred thirty-three (133) non-ambulatory residents, of which sixteen (16) may be bedridden. The facility also had an approved hospice waiver for sixteen (16) residents.

During today visit, the LPA toured the interior and exterior of the facility, and inspected resident bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. The facility had sufficient space to facilitate dining, laundry, visitation, meetings, and resident activities. There were no pools, nor bodies of water observed on the premises. Per staff, the facility did not store any firearms, nor ammunition at the facility.

Carbon monoxide detectors and the facility's signal system/ pull cords were tested at random. Fire extinguishers and required licensing posting were observed in visible areas of the facility.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in locked areas.



A review of facility records was initiated, including the facility's liability insurance, Infection Control Plan, and Emergency Disaster Plan. Due to time constraints, an additional visit is necessary to complete the annual inspection.

An exit interview was conducted with Administrator Vonda Boller, to whom a copy of this report, and the Licensee (LIC9058), were provided via email. An email read receipt confirms the documents were received.
Lizzette TellezTELEPHONE: (619) -76-2351
Sabel MartinezTELEPHONE: (619) 767-2301
DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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