<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600675
Report Date: 07/28/2021
Date Signed: 07/30/2021 08:09:27 PM

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: 520DATE:
07/28/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Stephanie Boudreau, Executive DirectorTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Manager (LPM), Laarni Santiago, County of San Diego Nurse Contractors Sandra Brackman and Elizar Perez; California Department Public Health (CDPH), Health Facility Evaluator Nurse (HFEN), Zenith Kihwaja with the HAI Program, conducted an on-site visit. LPA and team identified themselves and discussed the purpose of the visit with Executive Director (ED) Stephanie Boudreau.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, the team interviewed ED and Wellness Center Manager (WCM) Sheila Caldito and and conducted a walk-though of the facility. A debriefing was conducted with staff at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with ED and WCM and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided via electronic mail. An electronic receipt of confirmation was requested from ED, Stephanie Boudreau.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1