374600675-1-12-2026-08-AS-AGOH-DQ9VY7-20260112155039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600675
Report Date: 01/12/2026
Date Signed: 01/12/2026 03:50:46 PM

Document Has Been Signed on 01/12/2026 03:50 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	VI AT LA JOLLA VILLAGE		FACILITY NUMBER:	374600675
ADMINISTRATOR/ DIRECTOR:	BOUDREAU, STEPHANIE		FACILITY TYPE:	741
ADDRESS:	8515 COSTA VERDE BLVD		TELEPHONE:	(888) 674-4036
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY: 783		CENSUS: 489	DATE:	01/12/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Director of Resident Services Syril Jones		TIME VISIT/ INSPECTION COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on three (3) incidents reported to Community Care Licensing (CCL). LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Director of Resident Services Syril Jones. Note, LPA did step out for lunch from 12:25-1:25pm. Report 1: CCL received an Incident Report on 11/13/25 in which it was reported that a resident (identified as R1) had notified staff of a fall in their independent living apartment. Emergency services were contacted and R1 was assisted back into their wheelchair and was not transferred to the hospital. It was noted in the report that the day previous (11/6/25), R1 had a fall and was taken to the hospital and returned same day with several injuries. Per the report, after the second fall, R1 was advised of having a 1:1 caregiver due to the recent frequency of falls. Report 2: CCL received an Incident Report on 12/2/25 in which it was reported that a resident (identified as R2) reported pain to their side on 11/26/25. Emergency services were contacted and R2 was taken to the hospital where two (2) rib fractures were found. The report notes that R2 had a fall the day prior 11/25/25 and emergency services were called but R2 was not taken to the hospital. R2's responsible party and primary care provider were notified. Report 3: CCL received an Incident Report on 12/29/25 in which it was reported that on 12/23/25, a resident (identified as R3) was taken to the hospital by their family member due to back pain. There, it was found that R3 had compression fractures to two (2) vertebrae. Per the report, R3 returned to the facility same day. [Continued on LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/12/2026

NARRATIVE

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[Continued from LIC 809]

During today's visit, LPA conducted interviews and health and safety visits with R1, R2, and R3, as well as consultation with Director of Resident Services Jones. Interviews did not reveal any licensing or regulatory concerns.

Regarding R1, they are currently residing in the facility's SNF (Skilled Nursing Facility) to meet higher level care needs for a health condition unrelated to this incident. Per staff interviews, R1 and their responsible party have been advised of options to meet needs as R1 is no longer suitable for independent living, whether it be transitioning to the facility's Assisted Living (AL) area or remaining in Independent Living with a private 1:1 24/7 caregiver. File review of R1's records show care meeting attempts by the facility with R1 and communications with R1's responsible party post falls. Records also revealed the facility conducted updated assessments and care plans. Records also noted R1 had begun private caregiving services 11/14/25 but discontinued them 12/8/25. R1's updated physician's report (11/21/25) note R1 to be independent in Activities of Daily Living (ADLs).

Regarding R2, per interviews, it was revealed that R2 had declined transfer to the hospital by the paramedics after their initial fall, and staff promptly contacted emergency services once R2 notified them of a change in condition, thus there was no delay of medical attention by the facility. Regarding R3, per staff and resident interviews, R3 had no recent falls around the time of the incident.

LPA observed no immediate health and/or safety concerns during the visit.

No Deficiencies were cited during the visit as facility staff responded appropriately to each of the incidents reported. An exit interview was conducted with Executive Director Stephanie Boudreau to whom a copy of this report was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026

LIC809 (FAS) - (06/04)

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