374600823-4-29-2024-08-AS-LSIA-D4T5LA-20240429200251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600823
Report Date: 04/24/2024
Date Signed: 04/29/2024 08:03:37 PM

Document Has Been Signed on 04/29/2024 08:03 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:	HILLSIDE GARDEN RCFE		FACILITY NUMBER:	374600823
ADMINISTRATOR:	JASNA POPOVICH		FACILITY TYPE:	740
ADDRESS:	4892 HILLSIDE DRIVE		TELEPHONE:	(760) 730-3800
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	6	CENSUS: 6	DATE:	04/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator Marko Kolomijcev		TIME COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Vera Sivcev. Administrator Marko Kolomijcev and David Swagerty arrived shortly after.

According to the facility’s license, the facility has a maximum capacity of 6 residents, all of whom may be non-ambulatory. The facility serves residents age 60 and over. Hospice is approved for 6 residents.

During today’s inspection, there were a total of 6 residents in care. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by Marko, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was 74 F. Hot water temperature at taps accessible to residents were all compliant: Bathroom #1 sink was 107.8 F, Bathroom #2 sink was 107 F and Bathroom #4 sink was 119.4 F. Bathroom #3 was non-operable at this time.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. (continued on next page, LIC 809-C)

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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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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: HILLSIDE GARDEN RCFE	FACILITY NUMBER: 374600823
	VISIT DATE: 04/24/2024

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No pools or bodies of water were observed on the premises. Per Marko Kolomijcev no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed multiple staff and residents. LPA reviewed multiple staff and resident records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Marko, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC809 (FAS) - (06/04)

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