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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600675
Report Date: 10/12/2023
Date Signed: 10/12/2023 11:15:42 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2020 and conducted by Evaluator Nacole Patterson
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20200708085350
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: 561DATE:
10/12/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Amy Patterson, Associate Executive DirectorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Facility staff overmedicated resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Amy Patterson, Associate Executive Director.

On 7/8/2020 it was alleged that facility staff overmedicated a resident (R1). The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff and outside sources. Staff interview revealed that the medication in question was prescribed to be given as needed when R1 presented outside of their baseline behaviors. Staff interview revealed that staff were in communication with R1's physician, Hospice agency, and DPOA regarding the administration of the medication. Records review revealed daily documentation by staff regarding R1's behaviors and when the medication was given.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 08-AS-20200708085350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VI AT LA JOLLA VILLAGE
FACILITY NUMBER: 374600675
VISIT DATE: 10/12/2023
NARRATIVE
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Continued from LIC9099

Records review did not give evidence to the medication being administered to R1 when it was not needed or outside of the prescription. Records review corroborated that staff were in communication with R1's physician, Hospice agency, and DPOA regarding R1's medication regimen. Outside sources did not respond for interview.

Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Amy Patterson, Associate Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
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