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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881400
Report Date: 03/21/2023
Date Signed: 03/21/2023 12:06:43 PM

Document Has Been Signed on 03/21/2023 12:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FELICITA CAREFACILITY NUMBER:
371881400
ADMINISTRATOR:ROKSANDIC, DRAGANFACILITY TYPE:
735
ADDRESS:1661 ENCINO DRIVETELEPHONE:
(310) 994-3990
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 0DATE:
03/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dragan Roksandic, LicenseeTIME COMPLETED:
12:15 PM
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On March 21, 2023, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an announced pre-licensing inspection at the facility. LPA Nwogene met with Applicant, Dragan Roksandic and toured the interior and exterior of the facility.

Application: The application is for an Adult Residential Facility. The fire clearance has been granted for six (6) ambulatory residents, of which one (1) may be non-ambulatory.

Buildings and Grounds: The home is composed with living room, kitchen and dining room combination, five (5) client bedrooms, 3 restrooms, a staff room, laundry room, backyard, and a detached garage. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Dragan, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished and privacy is available. The dining and living room areas/furniture are clutter free and in good condition. Bathrooms were observed to have non-sliply textured floor and equipped with grab bar. The hot water was tested and measured at 116 degrees Fahrenheit which is within regulatory limits. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order. Central heating and air conditioning system installed with a central panel located in the living room to control entire house.

Storage and Supplies: Medications will be stored in a locked cabinet in the hallway, inaccessible to any unauthorized individuals. Secured cabinets in the hallway are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in the laundry room, inaccessible to clients, washing machine and dryer are all in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged.

CONTINUE ON LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: FELICITA CARE
FACILITY NUMBER: 371881400
VISIT DATE: 03/21/2023
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CONTINUED FROM LIC809

Activities: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition with a patio quipped with an umbrella to provide shade over the outside table and chairs. Activity supplies are present inside the home, including television, magazines, and games.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked kitchen cabinet, available only to authorized individuals. Trash cans have tight-fitting lid. Dishwasher will be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 34.1 degrees Fahrenheit and Freezer was measures at -6.1 degrees Fahrenheit.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan, Visitors Policy, Personal Rights, rights of resident council, a Facility Sketch (LIC 999), Labor Law Information, and Complaint Information.



Component III was completed during today's visit and a copy was emailed to Dragan Roksandic for future reference.

LPA Nwogene will inform the Centralized Applications Bureau (CAB) that the home is ready for licensure. and Applicant will be notified of the license approval.

An exit interview was conducted were this report was discussed with and provided to Dragan Roksandic.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC809 (FAS) - (06/04)
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