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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004738
Report Date: 01/10/2025
Date Signed: 01/13/2025 08:50:20 AM

Document Has Been Signed on 01/13/2025 08:50 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: 133CENSUS: 95DATE:
01/10/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Human Resources Director Mari PerezTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Continuation Annual Inspection visit. The LPA introduced himself and disclosed the purpose of the visit to Human Resources Director Mari Perez. Illeen Lund and Aurora Madueno assisted the LPA during the visit. 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.

The LPA conducted interviews and reviewed staff and resident records. The facility was clean, in good repair, and walkways were free of obstructions. There no pools, nor bodies of water observed on the premise. Per staff, no firearms, nor ammunition were stored at the facility. No deficiencies were cited on today's date.

An exit interview was conducted with Chief of Operations Aurora Madueno, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided via email. An email mail read receipt confirms the documents were received by Madueno.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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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