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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600675
Report Date: 06/04/2025
Date Signed: 06/04/2025 04:46:16 PM

Unsubstantiated


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
05/05/2025 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20250505110228
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: 513DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Associate Executive Director, Amy PattersonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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On June 4, 2025, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to present investigative findings. Upon arrival, LPA was greeted by Associate Executive Director, Amy Patterson, to whom she introduced herself and explained the purpose of the visit.

The Department investigated the complaint allegation listed above. The investigation comprised a facility tour, multiple interviews, and a thorough review of relevant records.

Background of the Complaint
On May 5, 2025, Community Care Licensing (CCL) received a complaint alleging unlawful eviction. Specifically, it was alleged that on April 27, 2025, when the hospital attempted to discharge Resident (R1) back to the facility, the staff initially refused to accept R1 back into their independent living apartment.

(Continue at LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
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 3
Control Number 08-AS-20250505110228
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: 06/04/2025
NARRATIVE
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(Continue from LIC 9099)

A Confidential Names List (LIC 811) was provided to identify the resident. A review of R1’s physician’s report from January 2025 and facility assessments indicated that R1 was considered fully independent and capable of making their own decisions.

Detailed Findings
A comprehensive review of R1’s medical records, hospital discharge instructions, and facility records revealed that R1 sustained a serious head injury after a fall in January 2025. Due to R1’s change in condition and heightened fall risk, R1 was discharged from the skilled nursing facility back to their apartment under a revised service care plan designed to meet their needs. This plan included 24/7 care and supervision, along with physical therapy to aid in regaining strength and mobility. R1 agreed to hire a private duty aide (caregiver) to assist with all activities of daily living (ADLs), including dressing, bathing, and transfers, to ensure their health and safety.

Interviews with R1, facility staff, and external sources confirmed that on April 4, 2025, staff were informed that R1 had canceled the services from the 24/7 caregiver agency effective April 3, 2025, as they no longer required assistance with ADLs. However, multiple interviews indicated that R1 did not officially notify staff as required by the admission agreement, which mandates that residents provide an updated physician’s report following hospitalization or changes in condition. R1 failed to provide such documentation to confirm that they were no longer a fall risk requiring 24/7 care and supervision with ADLs. Observations from staff and external sources consistently indicated that R1 still needed assistance with their ADLs. To ensure R1's health and safety, staff reestablished the 24/7 caregiver agency promptly and continued to provide necessary services.

On April 25, 2025, R1 experienced a change in condition and was readmitted to the hospital via 911 emergency services. Consequently, staff discontinued services from the 24/7 caregiver agency while R1 remained hospitalized.

(continue at LIC9099C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250505110228
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: 06/04/2025
NARRATIVE
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(Continue from LIC9099C)

On April 27, 2025, when staff were informed by hospital personnel that R1 was being discharged back to their apartment, they communicated the need for the 24/7 agency to provide a caregiver at the facility on short notice. Approximately an hour later, after confirming that R1’s Power of Attorney (POA) had secured caregiver services on April 26, 2025, staff contacted the hospital to arrange for facility staff to follow up with R1 upon arrival. Interviews confirmed that R1’s POA did not notify facility staff about the arrangements for R1’s discharge and the secured caregiver agency.

Conclusion
Based on the investigation, which included observations, interviews with key staff and external sources, and a review of relevant resident records, there was insufficient evidence to support the allegation of unlawful eviction. The evidence confirmed that R1 returned to their apartment on April 27, 2025, under 24/7 care and supervision. Facility staff would continue to monitor R1’s condition through health and safety checks as required by Title 22 regulations.

Therefore, this allegation is deemed unsubstantiated. An unsubstantiated finding means that while the allegation may have validity, there is not enough evidence to conclude that the alleged violation occurred.

An exit interview was conducted with Associated Executive Director Amy Patterson, who was provided with a copy of this report, the Confidential Names List (LIC 811), and the Licensee Appeal Rights (9058 03/22) at the conclusion of the visit.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3