372004738-12-20-2023-08-AS-AROS-CYPUVZ-20231220145558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 372004738
Report Date: 12/20/2023
Date Signed: 12/20/2023 02:56:06 PM

Document Has Been Signed on 12/20/2023 02:56 PM - 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 VILLAS		FACILITY NUMBER:	372004738
ADMINISTRATOR:	BOLLER, VONDA		FACILITY TYPE:	740
ADDRESS:	4282 BALBOA AVENUE		TELEPHONE:	(858) 273-1306
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY:	133	CENSUS: 102	DATE:	12/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrator, Vonda Boller		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required 22 month Inspection. LPA Rodgers was granted entry into the facility by Administrator, Vonda Boller, after identifying herself and stating the purpose of the inspection. The facility serves 133 non-ambulatory elderly residents, age 60 and above, of which 16 may be bedridden in rooms #134-#147 only. There is an approved Hospice Waiver for 16 residents. This is a three-story complex, and the facility does not feature a secured perimeter. LPA was accompanied by Administrator Boller, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on November 2023. Exterior and interior passageways were free from obstructions. According to Administrator Boller, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident units and LPA Rodgers observed functionality of signal system. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars, and nonskid mats were present in residents’ showers. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CANYON VILLAS	FACILITY NUMBER: 372004738
	VISIT DATE: 12/20/2023

NARRATIVE

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Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medication room is secured and has a locked medication cart, medications were labeled and kept in compliance with label instructions.

LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA Rodgers also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) were provided to the Administrator Boller, whose signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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