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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601124
Report Date: 12/15/2021
Date Signed: 12/16/2021 08:56:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:WOODLAND BORDEN CAREFACILITY NUMBER:
374601124
ADMINISTRATOR:MIRJANA VUKOVICHFACILITY TYPE:
740
ADDRESS:819 WULFF STREETTELEPHONE:
(760) 744-4829
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:6CENSUS: 5DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Mirjana Vukovich and George VukovichTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required 1 - Year Visit. LPA was greeted by Licensee Mirjana Vukovich and Staff George Vukovich, identified himself, and discussed the purpose of the visit.

In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.

An exit interview was conducted with Licensee Mirjana Vukovich. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail to licensee Mirjana Vukovich. A read receipt email confirms the receipt of these documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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