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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601124
Report Date: 12/15/2023
Date Signed: 12/15/2023 01:21:10 PM


Document Has Been Signed on 12/15/2023 01:21 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: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:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:ADMINISTRATOR, MIRJANA VUKOVICHTIME COMPLETED:
01:28 PM
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On December 15, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Administrator, Mirjana Vukovich. The LPA introduced herself and stated the purpose of the visit.

LPA Mixson toured the facility along with the Administrator and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home, located at 819 Wulff Street San Marcos, CA. 92069. Physical Plant: The facility phone number is (760)744-4829 and is operable. The LPA observed the residents bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected facility bathrooms, and the hot water temperature was tested and tested within regulations. The bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something," the Ombudsman, "Personal Rights" postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the resident and staff files they were locked and inaccessible to residents in care. Medications: were locked and inaccessible to residents. The overall facility is clean, welcoming , and the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision Facility has sufficient staff, three at the time of this visit, and the residents are participating in the noon day meal. Records Review: The LPA reviewed five resident files, and four staff files. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted and a copy of this report was given to the Administrator, Mirjana Vukovich.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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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