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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600675
Report Date: 10/25/2022
Date Signed: 10/25/2022 03:34:53 PM


Document Has Been Signed on 10/25/2022 03:34 PM - It Cannot Be Edited

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: 489DATE:
10/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director, Stephanie BoudreauTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a case management visit to complete a review regarding a self-reported death of Resident 1 (R1) (See LIC 811 for confidential names) received by CCL on October 24, 2022. LPA met with Executive Director, Stephanie Boudreau.

LPA reviewed R1's facility file, toured the facility, and conducted interviews with staff about events leading up to the death. C1 resided at the facility since September 15, 2021. On October 21, 2022, at 6:53 a.m. R1 passed away at the facility, unknown cause of death. During the case management visit LPA reviewed R1's relevant records. LPA requested the death certificate.

No deficiencies were cited during the visit.

An exit interview was conducted with Associate Executive Director, Milos Blagojezic, to whom a copy of this report and the Licensee Rights (LIC9058 01/2016) were provided at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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