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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600675
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:45:17 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/08/2022 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20220808163156
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: 518DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Executive Director, Stephanie BoudreauTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff did not treat resident with respect
Staff did not meet resident's dietary needs
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 discussed the purpose of the visit.

The Department investigated the above listed complaint allegations. The investigation consisted of a tour of the facility, multiple interviews with staff and outside sources, and records review, including medical records and other relevant evidence pertinent to this investigation.

On August 8, 2022, Community Care Licensing (CCL) received a complaint alleging that facility staff did not treat Resident #1 (R1) with respect. It was alleged that the staff member in question did not express sympathy after a personal loss. It was also alleged that R1 felt intimidated because the same staff member glared and made inappropriate comments to them.

(Continue on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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-20220808163156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 374600675
VISIT DATE: 11/10/2022
NARRATIVE
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(Continue from LIC9099)

The dates and/or times of when this occurred or of any other examples of when R1 was not treated with respect was not identified. The Department was unable to obtain credible information from resident interviews or outside sources corroborating this allegation. Interviews with staff indicated they had not seen or witnessed a staff member not treating residents with respect. The staff member in question denied the allegation.

It was also alleged that staff did not meet residents’ dietary needs. A review of R1's residential agreement indicates that provider will accommodate customary and reasonable special diets that are prescribed by physician. Record reviews showed a list provided by the resident of highly and moderately reactive foods (allergies) which lists several foods items. However, none of these items were found in the doctor’s notes. Interviews revealed that the facility had been following this list to “accommodate” R1. There were no records shown that the doctor prescribed such modifications based on medical necessity. Based on interviews and records reviewed, there is insufficient evidence to prove the allegation that facility failed to adhere to resident's dietary needs.

Based on the results of the investigation, which consisted of observations, interviews with key staff and outside sources, and review of pertinent resident and facility records there was insufficient evidence to support both of the allegations listed in this report. Therefore, these allegations are 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, to whom a copy of this report, Confidential Names List (LIC 811) and Licensee Appeal Rights (9058 01/16) 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: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/08/2022 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20220808163156

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: DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Executive Director, Stephanie BoudreauTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide a safe environment
Staff did not meet resident's needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 discussed the purpose of the visit.

The Department investigated the above listed complaint allegations. The investigation consisted of a tour of the facility, multiple interviews with staff and outside sources, and records review, including medical records and other relevant evidence pertinent to this investigation.

On August 8, 2022, Community Care Licensing (CCL) received a complaint alleging that facility staff did not provide a safe environment. It was specifically alleged that a light fixture in Resident’s (R1) apartment was a safety hazard and was taken down due to an alleged leak inside the fixture. It was also alleged the light fixture, a large chandelier, was left on the floor because facility management did not allow maintenance staff to clean it and put it back up.
(Continue on LIC9099C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20220808163156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 374600675
VISIT DATE: 11/10/2022
NARRATIVE
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(Continue from LIC9099A)
On 8/16/2022, during a tour of the facility, the apartment was observed to be clean and free from any safety hazards. The light fixture was observed to be sitting on the floor. There was no observable evidence of moisture or mold on the ceiling where the light fixture used to be hung. In addition, review of inspection records indicated that there was no evidence of a water leak affecting R1’s apartment with Development Services Department & Code Enforcement with the City of San Diego in November of 2021, (exact date unknown). The city inspector requested the light fixture to be removed so that they could perform and inspection of the area. Upon inspection no evidence of moisture or mold was found. Based on observations, review of records and interviews with residents, staff, and outside sources there was no evidence found to support this allegation.

It was alleged that staff facility staff did not meet R1’s needs because they did not agree to clean a light fixture. R1 claimed that the light fixture had accumulated rust due to water damage. This allegation is in relation to the above unfounded allegation regarding the light fixture. Once it was determined that the light fixture was not damaged due to a water leak, facility management informed R1 that cleaning the resident’s chandelier light fixture was outside the scope of the routine housekeeping services. Subsequently, facility staff suggested for R1 to consider a local company that specializes in chandelier light fixture cleaning.

It was also alleged facility staff did not meet R1’s needs when they requested transportation services to go to a non-medical appointment on demand without making prior arrangements with the facility concierge. The resident handbook states that transportation is provided based on availability and that requests must be made in writing 72 hours in advance.

Based on the results of the investigation, which consisted of observations, interviews with key staff and outside sources, and review of pertinent resident and facility records there was no evidence found to support any of the allegations listed in this report. The Department has found that the complaint allegations were unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

An exit interview was conducted with Executive Director, Stephanie Boudreau, to whom a copy of this report, Confidential Names List (LIC 811) and Licensee Appeal Rights (9058 01/16) 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: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4