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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600675
Report Date: 07/22/2021
Date Signed: 07/30/2021 08:12:06 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:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Milos Blagojevic, Associate Executive DirectorTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Laarni Santiago visited the facility to conduct an annual required licensing inspection. LPA was met by Associate Executive Director, Milos Blagojevic, and was granted entry into the facility and discussed the purpose of the visit.

During today's visit, LPA toured the facility accompanied by Mr. Blagojevic, and verified compliance with infection control practices. LPA and Mr. Blagojevic reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs to promote hand hygiene was observed in restroom; face coverings are worn by staff; hand sanitizer/hand washing stations are readily available; a designated visitation area; emergency agencies’ contact information are updated and available to staff and residents; and an adequate supply of cleaning products and PPE supplies.

No deficiencies were cited during today’s visit. An exit interview was conducted with Mr. Blagojevic, and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to them via email. An electronic receipt of confirmation was requested to be sent by the Association Executive Director upon receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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