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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600675
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:54:30 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
11/16/2023 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20231116081523
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: 512DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Executive Director, Stephanie BoudreauTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Licensee did not follow the terms of the admission agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Executive Director, Stephanie Boudreau to whom she identified herself and discussed the purpose of the visit.

The Department investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility, multiple interviews with staff, residents, and outside sources, and records review.

On November 16, 2023, Community Care Licensing (CCL) received a complaint alleging that the facility did not follow the terms of the admission agreement. It was specifically alleged that after being discharged from the hospital, resident (R1) [a LIC 811 Confidential Names List was provided to staff to identify the resident] was not allowed back into their apartment located in the independent living venue of the community.
Continue at LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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 3
Control Number 08-AS-20231116081523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VI AT LA JOLLA VILLAGE
FACILITY NUMBER: 374600675
VISIT DATE: 11/30/2023
NARRATIVE
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Continue from LIC9099

A review of facility and medical records indicated that on August 28, 2023, R1 tripped on carpet and fell in their apartment. R1 received immediate medical attention and was transported to the hospital by emergency personnel. A review of R1’s medical reports indicated that R1 sustained a severe thumb fracture. R1 was admitted to the hospital for orthopedic hand surgery and was placed into a thumb spica splint. The medical report indicated that R1 showed behaviors with elements of paranoia and dementia. On August 30, 2023, according to the medical report, R1 was discharged with non-weight-bearing instructions on the right thumb and to keep the dressings and splint clean, dry, and intact. A review of the care conference report that took place before discharge with R1, R1's responsible party, and the assigned care manager stated that R1 would require 7/24 care in their independent living apartment after rehabilitation services were provided in skilled nursing aka “Care Center” located in the community. During the care conference, R1 was informed of what was required for them to be discharged back to their independent living apartment when there was a change in condition. Facility management informed R1, as stated in the admissions agreement signed on January 18, 2021, that they would need to have 24-hour caregivers and adhere to the safety precautions required to be in place due to R1’s fall risk condition and cognitive status. Facility management also informed R1 of the option to move out of the facility to another community and that a list of facilities would be provided to assist with finding another community. R1 and R1’s responsible party declined the moving out option and opted for R1 to stay at the care center until further medical evaluations were completed to establish if R1 could return to independent living. During interviews with facility staff, it was indicated that R1 and R1’s responsible party were offered a copy of the "resident rights" but declined acceptance. An interview with R1 confirmed their understanding of their care service plan while living in the care center. In addition, during an interview, R1 confirmed that the facility would hold their apartment while they remained in the care center and that they could access their apartment as needed to obtain any necessary items as long as they were assisted by facility staff. During the investigation, it was determined that the R1 entered into a continuing care residency agreement at the community on January 18.2021. The agreement stipulated that upon transfer to the care center after a hospital stay, the monthly fee would continue to apply if the resident intended to return to the apartment.

Continue at LIC9099C
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20231116081523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VI AT LA JOLLA VILLAGE
FACILITY NUMBER: 374600675
VISIT DATE: 11/30/2023
NARRATIVE
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Continue from LIC9099


Based on the results of the investigation, which consisted of observations, interviews with key staff, R1, and outside sources, and a review of pertinent resident and facility records there was no evidence found to support the allegation listed in this report. The Department has found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted with Executive Director, Stephanie Boudreau, to whom a copy of this report, Confidential Names List (LIC 811), and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3