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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881534
Report Date: 07/02/2024
Date Signed: 07/02/2024 11:21:53 AM


Document Has Been Signed on 07/02/2024 11:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:WOODLAND BORDEN CAREFACILITY NUMBER:
371881534
ADMINISTRATOR:VUKOVICH, GEORGEFACILITY TYPE:
740
ADDRESS:819 WULFF STTELEPHONE:
(760) 744-4829
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:6CENSUS: 5DATE:
07/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:George Vukovich, AdministratorTIME COMPLETED:
11:30 AM
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On 7/2/24 at 9:16am Licensing Program Analyst (LPA) Javina George made an announced visit to the facility for the purpose of conducting a prelicensing inspection-Change of Ownership (CHOW) with residents in care. The facility has requested a hospice waiver for four (4). There are currently two (2) residents receiving hospice care.

LPA met with Administrator/Applicant George Vucovich who assisted in the tour of inside and outside of the facility and the evaluation. On 01/12/24 the San Marcos Fire Department approved the facility for 6 non-amubulatory persons. The facility is a single story home consisting of 6 bedrooms, 1 of which is for staff/live in caregiver, and four (4) bathrooms, 3 of which are for residents to use.

In addition there is a living room, kitchen, backyard with a covered patio, garden, and a garage which is the staff area. There is also a shed that is being used for storage, and a built in smoker the backyard. The medications are locked inside a cabinet inside the kitchen. There are no pools or bodies of water or known guns or ammunition on the premises.

The facility was observed to have the required postings, and operable smoke and carbon monoxide detectors, and fully charged fire extinguishers. The hot water was tested and found to be within regulatory limits. The facility utilizes pendants. Each resident is issued a pendant to wear around their neck upon admission to use in the event that assistance is needed.

The facility was evaluated in accordance with the California Code of Regulation (CCR), Title 22 Chapter 6, Division 8. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided with Applicant/Administrator George Vucovich.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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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