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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004738
Report Date: 07/12/2023
Date Signed: 07/12/2023 02:29:32 PM


Document Has Been Signed on 07/12/2023 02:29 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:BOLLER, VONDAFACILITY TYPE:
740
ADDRESS:4282 BALBOA AVENUETELEPHONE:
(858) 273-1306
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:133CENSUS: 105DATE:
07/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director, Vonda Boller, and Cheif of Operations, Aurora Madueno TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Case Management - Incident visit. The LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Chief of Operations, Aurora Madueno. Executive Director, Vonda Boller, arrived during the visit.

Today's visit was in response to an Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office, (received on 7/7/23) involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1].

During today’s visit, the LPA performed a facility tour, welfare check, and secured pertinent records. No immediate health, nor safety concerns were observed, and no deficiencies were issued. At this time, future visits may be necessary.

An exit interview was conducted with Executive Director Vonda Boller, and Chief of Operations, Aurora Madueno and to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058) were provided.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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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