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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 04:48:45 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
05/22/2025 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20250522091750
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:
12:40 PM
MET WITH:Associate Executive Director, Amy PattersonTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff violated resident's privacy.
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 conducted an investigation into the complaint allegation listed above, which included a facility tour, multiple interviews, and a thorough review of relevant records.

Background of the Complaint
On May 22, 2025, Community Care Licensing (CCL) received a complaint alleging that staff violated a resident's privacy. Specifically, it was alleged that on May 16, 2025, facility staff knocked on R1's door and, upon receiving no answer, entered without R1's knowledge or consent. Furthermore, on May 19, 2025, facility staff called 911, leading law enforcement to conduct a wellness check on R1. A Confidential Names List (LIC 811) was provided to identify the resident.
(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-20250522091750
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 LIC9099)

A review of R1’s most recent physician’s report from January 2025 and facility assessments indicated that R1 was considered fully independent and capable of making their own decisions.

Investigation Findings
A detailed review of R1’s medical records, hospital discharge instructions, and facility records revealed that R1 sustained a serious head injury from a fall in January 2025. Due to a change in condition and increased fall risk, R1 was discharged from the skilled nursing facility back to their apartment under a revised service care plan. This plan included 24/7 care and supervision, as well as physical therapy to aid in regaining strength and mobility. R1 agreed to retain a private duty aide (caregiver) to assist with activities of daily living (ADLs), such as dressing, bathing, and transfers, ensuring R1's health and safety.
R1 was also subject to health and safety checks by facility staff to monitor any changes in condition, including daily check-ins with the private duty aide agency. This protocol was established by the facility for all residents, in compliance with Title 22 regulations, Division 6, Chapter 8, Article 08, which mandates regular observation of residents for changes in functioning and appropriate assistance when needed.
The regulation (87466, Observation of the Resident) specifically outlines that the licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observations reveal unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or physical health condition are observed, the licensee must ensure that such changes are documented and brought to the attention of the resident's physician and responsible person.

During interviews with staff and external sources, it was reported that access to R1’s apartment was being denied, preventing staff from conducting the required wellness checks. On May 16, 2025, facility staff knocked on the door, and when there was no answer, they announced themselves and entered to conduct the wellness check. Staff expressed concern that, despite multiple attempts to gain access, the 24/7 caregivers were instructed not to open the door to facility staff. On May 19, 2025, facility staff sought assistance by calling 911, prompting law enforcement to conduct the wellness check.

(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-20250522091750
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)

Staff stated during multiple interviews that during instances when the caregiver on duty did not open the door, staff announced themselves and entered R1’s apartment. In all cases, R1 was aware of the visits and had granted permission for the wellness checks.

Conclusion
Based on the investigation results, which included observations, interviews with key staff and external sources, and a review of pertinent resident records, there was insufficient evidence to support the allegation that staff violated R1’s privacy by entering the apartment after knocking and announcing themselves.

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 Associate Executive Director Amy Patterson, who received 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