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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004738
Report Date: 08/24/2023
Date Signed: 08/25/2023 09:49:05 AM


Document Has Been Signed on 08/25/2023 09:49 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:BOLLER, VONDAFACILITY TYPE:
740
ADDRESS:4282 BALBOA AVENUETELEPHONE:
(858) 273-1306
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:133CENSUS: 106DATE:
08/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Chief of Operations, Aurora Madueno, Executive Director, Vonda Boller, Executive Nursing Coordinator, Ilene LundTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Case Management - Incident visit. The LPA identified himself, and discussed the purpose of the visit with Chief of Operations, Aurora Madueno.

Today's visit was in response to an LIC624 Incident Report, and SOC 341 Report of Suspected Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/24/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA secured pertinent records and conducted interviews. No deficiencies were observed or cited during today's visit, but future visits may be necessary.

An exit interview was conducted with Boller and Lund, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided via electronic mail. An electronic mail read receipt confirms the documents were received.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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