374600675-2-28-2025-08-AS-SJAB-DEELL5-20250303075030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600675
Report Date: 02/28/2025
Date Signed: 02/28/2025 04:49:27 PM

Unsubstantiated

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
02/03/2025 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20250203115111

FACILITY NAME:	VI AT LA JOLLA VILLAGE		FACILITY NUMBER:	374600675
ADMINISTRATOR:	BOUDREAU, STEPHANIE		FACILITY TYPE:	741
ADDRESS:	8515 COSTA VERDE BLVD		TELEPHONE:	(858) 646-7700
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	783	CENSUS: 524	DATE:	02/28/2025
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Executive Director, Stephanie Boudreau		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not provide a comfortable room temperature for resident resulting in injury

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 explained the purpose of the visit.

The Department investigated the above-listed complaint allegation. The investigation included a facility tour, multiple interviews, and a detailed review of relevant records.

On February 3, 2025, Community Care Licensing (CCL) received a complaint alleging that facility staff failed to maintain a comfortable temperature for Resident 1 (R1), resulting in injury. [A Confidential Names List (LIC 811) was provided to staff to identify the resident.]

(Continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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 4

Control Number 08-AS-20250203115111

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: 02/28/2025

NARRATIVE

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(Continue from LIC9099)
It was alleged that on January 18, 2025, R1 experienced an unwitnessed fall in their apartment due to sleep deprivation caused by cold temperatures. Specifically, it was claimed that lack of sleep led to low blood pressure and dizziness, causing R1 to fall in the bathroom during the night. As a result, R1 sustained a traumatic left subdural hematoma. On January 25, 2025, R1 was transferred to a skilled nursing facility for continued treatment and recovery. On February 7, 2025, R1 was discharged back to their independent living apartment under 24/7 care and supervision due to a change in condition. R1 required assistance with all activities of daily living and was determined to be a high fall risk due to the recent fall, poor balance, general weakness, and low blood pressure.

On February 10, 2025, LPA visited R1’s apartment and observed it to be clean and free of odors. Two thermostats were present, including one inside R1’s bedroom. The bedroom thermostat displayed a temperature of 81°F, set at 75°F. However, R1 preferred using the thermostat in “manual mode” instead of “auto mode” meaning the heat remained on beyond the set temperature. Conversely, if R1 turned off the unit and forgot to turn it back on, the temperature could drop below their desired comfort level. Facility maintenance recommends keeping thermostats in “auto mode” for optimal efficiency. During the visit, LPA noted the apartment felt very warm. According to Title 22 regulations, the temperature was within the required range (68 - 85°F). The second thermostat, located in the main living room, displayed 76°F, aligning with the standard home temperature range of 68 - 76°F.

[Note: Each apartment in the facility has its own HVAC unit, and thermostats are located inside individual units, allowing residents full control over their room temperature settings.]

During the visit, R1 pointed to the vent and indicated that cold air was coming through. However, LPA observed a vent deflector (a transparent cover directing airflow upwards) to prevent direct airflow. LPA did not feel cold air coming through the vent. During the visit, R1 was in bed under blankets and stated they still felt cold, with cold hands to the touch. Interviews with R1’s private caregivers consistently indicated that the apartment temperature was comfortable and, at times, too warm. A review of caregivers’ daily care notes for February 2025 showed that R1 had asked caregivers on several ocassions to turn off the heat because they felt too warm. The caregiver present during the visit confirmed they had no concerns about the apartment’s temperature but acknowledged that R1 continued to feel cold.
(continue at LIC9099C)

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20250203115111

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: 02/28/2025

NARRATIVE

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(continue from LIC9099C)

On August 27, 2024, CCL had previously investigated and delivered unsubstantiated findings regarding the same allegation. Interviews with facility management and the director of engineering revealed that the facility had been addressing R1’s concerns since November 13, 2023. In response, facility maintenance replaced the thermostats twice in November and December 2023 because R1 believed they were old and inaccurate. Additionally, at R1 requested the thermostats to be relocated twice in December 2023 and January 2024. Maintenance also checked and replaced the apartment vents.

On April 8, 2024, R1 hired an independent HVAC consultant to investigate the heating and airflow in their apartment. The consultant reported placing sensors inside the apartment. The readings showed no issues with room temperature. The sensors monitored temperatures continuously for several days, both during the day and night. The consultant’s findings aligned with studies conducted by the facility’s engineers and maintenance staff. Additionally, interviews with multiple residents living on the same floor near R1’s apartment did not reveal any HVAC-related complaints.

A review of R1’s medical records disclosed a significant list of medical conditions, including recurring urinary tract infections (UTIs), sleep disorder, Raynaud’s syndrome, primary anemia, osteoarthritis (left hip and both knees), gait difficulty, weight loss, obstructive sleep apnea, primary insomnia, chronic weakness, and acute cough. Medical notes indicated that symptoms associated with these conditions include low blood pressure, dizziness, and feeling cold. For instance:
• Raynaud’s disease causes areas such as fingers and toes to feel numb and cold.
• Primary anemia, particularly iron deficiency anemia, can cause constant cold sensations due to poor blood circulation and oxygen distribution, leading to cold hands and feet, even in warm environments.

Based on the results of the investigation, which consisted of observations, interviews with key staff and outside sources, and a review of pertinent resident records there was insufficient evidence to support the allegation that staff did not provide a comfortable room temperature for R1 resulting in injury.

(continue at LIC9099C)

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20250203115111

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: 02/28/2025

NARRATIVE

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(Continue from LIC9099C)

Therefore, this allegation is unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence that the alleged violation occurred.

An exit interview was conducted with Executive Director Stephanie Boudreau, who was provided with a copy of this report, the Confidential Names List (LIC 811), and the Licensee Appeal Rights (9058 03/22) at the conclusion of the visit.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC9099 (FAS) - (06/04)

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