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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600675
Report Date: 08/18/2023
Date Signed: 08/18/2023 03:21:27 PM


Document Has Been Signed on 08/18/2023 03:21 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: 524DATE:
08/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Stephanie Boudreau, Executive DirectorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to the facility. LPA introduced herself, was granted entry into the facility, and met with Stephanie Boudreau, Executive Director, and Sheila Caldito, Wellness Center Manager, to whom she disclosed the purpose of the visit.

The visit was initiated in response to a self-reported incident involving Resident #1 (R1) [LIC 811 Confidential Names List was provided to identify the resident] that occurred on August 12, 2023. The Licensee's authorized representative self-reported the incident by submitting a Special Incident Report and an SOC 341 - Report of Suspected Dependent Adult/Elder Abuse to Community Care Licensing (CCL), which were received by CCL on August 16, 2023.

During today's visit, LPA toured the facility, obtained copies of resident records, and observed residents in care. No immediate health and/or safety concerns were observed.

No deficiencies were cited during today's visit. This report was reviewed with Stephanie Boudreau, and copies of the report and Licensee/Appeal Rights were provided to the Executive Director at the conclusion of the visit. Her signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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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