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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004738
Report Date: 07/10/2024
Date Signed: 03/07/2025 04:07:33 PM

Document Has Been Signed on 03/07/2025 04:07 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 VILLASFACILITY NUMBER:
372004738
ADMINISTRATOR/
DIRECTOR:		BOLLER, VONDAFACILITY TYPE:
740
ADDRESS:4282 BALBOA AVENUETELEPHONE:
(858) 273-1306
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 133CENSUS: DATE:
07/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Executive Director Vonda BollerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Case Management visit. The LPA identified himself, and discussed the purpose of the visit with Executive Director Vonda Boller. Ileend Lund assisted the LPA during the visit.

Today's visit was in response to an LIC 624 Incident Report, which the licensee self-submitted to the CCLD San Diego Regional Office (received on 06/25/2024), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, the LPA collected and reviewed records, including a physician's report, identification emergency profile, pre-appraisal, and care plan. Guidance was provided by the LPA and no deficiencies were cited on today's date.

An exit interview was conducted with Boller, to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058), were provided via electronic mail. An electronic mail read receipt confirms the documents were received by Boller.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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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