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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600675
Report Date: 11/02/2020
Date Signed: 11/03/2020 10:44:30 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VI AT LA JOLLA VILLAGEFACILITY NUMBER:
374600675
ADMINISTRATOR:BOUDREAU, STEPHANIEFACILITY TYPE:
741
ADDRESS:8515 COSTA VERDE BLVDTELEPHONE:
(858) 646-7700
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:783CENSUS: 540DATE:
11/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Stephanie Boudreau, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Laarni Santiago, conducted an unannounced Case Management virtual visit via FaceTime due to COVID-19. LPA spoke with Administrator, Stephanie Boudreau. LPA identified herself and stated the purpose of the virtual visit.

The San Diego Regional Office was notified of the death of Resident #1 (R1, see List of Confidential Names) on October 30th, 2020. During the televisit, LPA interviewed administrator and requested additional records. At this time, further investigation is required and future visits may be necessary.

No deficiencies were issued.

An exit interview was conducted and a copy of this report, List of Confidential Names, and Licensee's Rights (9058 01/16) were provided to the Administrator via electronic mail. An e-mail read receipt confirms acceptance of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
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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