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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600675
Report Date: 12/05/2022
Date Signed: 06/05/2023 12:30:49 PM


Document Has Been Signed on 06/05/2023 12:30 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
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: 521DATE:
12/05/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Stephanie Boudreau, AdministratorTIME COMPLETED:
01:50 PM
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Regional Manager (RM) Icela Estrada and Licensing Program Manager (LPM) Denise Powell conducted a virtual office meeting with facility administrator Stephanie Boudreau, to discuss respective roles and responsibilities and promote collaborative communication. During today's meeting, RM, LPM and administrator shared perspectives on different communication styles, and identified mutual goals of ensuring quality care and services to residents. RM, LPM and administrator agreed on supportive measures to foster continued collaboration between the facility and the Department.

An exit interview was conducted and a copy of this report, along with licensee rights (LIC 9058) was provided via email to administrator Boudreau. LPM will follow up to provide requested guidance and clarification on Provider Information Notice (PIN) 22-28.1-ASC regarding best practices for visitation.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Denise PowellTELEPHONE: 619-301-9770
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022
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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