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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600675
Report Date: 05/26/2021
Date Signed: 05/27/2021 07:26:29 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: 518DATE:
05/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Stephanie Boudreau, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Laarni Santiago conducted an unannounced Case Management visit to verify that Staff #1 (Licensee provided LIC 811 Confidential Names to identify S1) is no longer working at the facility. LPA was met by Stephanie Boudreau, Administrator, identified herself and explained the purpose of the visit.

On May 20th, 2021, San Diego Regional Office received a Decision and Order prohibiting S1 from employment in, presence in, and contact with clients of, any facility licensed by the Department for the remainder of their life. The Decision and Order shall become effective on May 31st, 2021. Human Resource Director (HR) and Administrator verified that S1 has never been hired as an employee of the facility. HR received a copy of the Decision and Order.

During the visit today, LPA verified by staff interview that S1 has never been employed by the facility.

No deficiencies cited during today's visit. An exit interview was conducted with Administrator and a copy of this report, LIC 811 and Licensee Appeal Right was provided to Administrator for facility records.


**This is an amended report from the original report dated 05/26/2021**
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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