374600675-7-31-2026-08-AS-LTEZ-DWNUWX-20260805155729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600675
Report Date: 07/31/2026
Date Signed: 07/31/2026 10:04:40 AM

Substantiated

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
07/19/2026 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20260719082836

FACILITY NAME:	VI AT LA JOLLA VILLAGE		FACILITY NUMBER:	374600675
ADMINISTRATOR:	BOUDREAU, STEPHANIE		FACILITY TYPE:	741
ADDRESS:	8515 COSTA VERDE BLVD		TELEPHONE:	(888) 674-4036
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	783	CENSUS: 547	DATE:	07/31/2026
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Director of Resident Services, Syril Jones		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff did not provide a resident with a bedroom
Staff did not ensure resident was provided privacy

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Director of Resident Services, Syril Jones. LPA spoke with Executive Director, Stephanie Boudreau via telephone, while at the facility.

During the investigation, LPA briefly toured the facility, requested records, and interviewed staff and residents. It was alleged staff did not provide a resident with a bedroom and staff did not ensure resident was provided privacy. It was reported that Resident #1 (R1) has been sleeping in a recliner in one of the memory care unit’s activity rooms due to a flood in another resident's room. The Care Center Administrator (CCA) explained Resident #2 (R2)’s room endured the flood, not R1’s room. However, R2 was relocated to R1’s room. R1 was removed from their private room and placed in one of their activity room’s that has glass doors/windows that was kept open, exposing R1. R1 was not accorded with dignity or privacy with direct care. R1 has been in the activity room for approximately three (3) or more weeks. Everyone visiting and walking by is able to observe R1 sleeping on the recliner. Continued on LIC 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20260719082836

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: 07/31/2026

NARRATIVE

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On 07/20/26, LPA observed R1 asleep on the recliner in the activity room, with the glass doors wide open. R1’s belongings were not in the activity room with R1. LPA requested privacy for R1 when providing direct care until the issue was resolved. Therefore, staff asked another staff to obtain a privacy shade to assist with privacy for R1 during direct care. Prior to LPA requesting privacy, the facility was not using any privacy shades to protect R1’s privacy and dignity. Staff interviews confirmed R1 was moved from their room twice (2) due to repairs, not related to their unit. Staff also confirmed the flood was not in R1’s room, but in R2’s room. Instead of moving R2 to another private room, once affected by the flood the CCA relocated R1 to an activity room and gave R2, R1’s private bedroom. R1 was not accorded with dignity or privacy with direct care or their own personal bedroom. The CCA's interview revealed they believed it was appropriate to move R1 out of their private room due to R1 preferring to sleep in a recliner. On 07/21/26, both residents were relocated to their own private rooms.

Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations were found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Services, Syril Jones whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20260719082836

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/28/2026 Section Cited CCR 87307(a)(2)(B)	1 2 3 4 5 6 7	Personal Accommodations and Services. Living accommodations...shall be related to the facility's function. The facility shall...and privacy for the residents ...in the facility. No room commonly used for other purposes shall be used as a sleeping room for any resident.	1 2 3 4 5 6 7	Executive Director (ED) stated R1 was relocated back to their private room on 07/21/26. In addition, vendor training will provided to staff in memory care unit regarding Personal Accommodations and Services. Proof of training due by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure that 1 out of 545 [R1] residents were provided with a bedroom. R1 was made to sleep in the activity room, which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	This is an amended version of the original report created on 07/31/26
Type B 08/28/2026 Section Cited CCR 87468.2(a)(1)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities. To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications...and meetings of resident and family groups.	1 2 3 4 5 6 7	Executive Director (ED) stated R1 was relocated back to their private room on 07/21/26. In addition, vendor training will provided to staff in memory care unit regarding Personal Rights. Proof of training due by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure that 1 out of 545 [R1] residents were provided privacy. R1 was made to sleep in the activity room with no privacy with direct care, which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	This is an amended version of the original report created on 07/31/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

LIC9099 (FAS) - (06/04)

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