374600675-12-15-2022-08-AS-DPOL-CMKSUH-20221229131112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600675
Report Date: 12/15/2022
Date Signed: 12/15/2022 02:53:28 PM

Unfounded

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
12/01/2022 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20221201145429

FACILITY NAME:	VI AT LA JOLLA VILLAGE		FACILITY NUMBER:	374600675
ADMINISTRATOR:	BOUDREAU, STEPHANIE		FACILITY TYPE:	741
ADDRESS:	8515 COSTA VERDE BLVD		TELEPHONE:	(858) 646-7700
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	783	CENSUS: 518	DATE:	12/15/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Executive Director, Stephanie Boudreau		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff did not adress mold issue

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 allegation. The investigation consisted of a tour of the facility, multiple interviews with staff and outside sources, and records review.

On December 1, 2022, Community Care Licensing (CCL) received a complaint alleging that facility staff did not address mold issue. It was specifically alleged that facility staff did not address mold problem under the bathroom sink of a resident due to the faucet leaking. It was alleged that on November 17, 2022, mold was observed under the sink.

(Continue on LIC9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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-20221201145429

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: 12/15/2022

NARRATIVE

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(Continue from LIC9099)

On December 8, 2022 during the 10-Day visit, review of maintenance records and staff interviews indicated the repair under the sink was completed on October 10, 2022 by replacing the faucet and checking for moisture. In addition, review of an inspection report that was completed on October 11, 2022, by an outside independent property restoration company concluded there were no signs of moisture or mold under the sink. The resident in question was verbally informed of the inspection results. Photographs obtained during the investigation showed areas of discoloration but no visible signs of mold or moisture. On December 15, 2022, an inspection under the sink was performed and there were no observable signs of moisture or mold. Based on observations, review of records and interviews with staff, and outside sources there was no evidence found to support this allegation.

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 this allegation. The Department has found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Executive Director, Stephanie Boudreau, to whom a copy of this report, and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

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