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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601655
Report Date: 01/12/2024
Date Signed: 01/12/2024 10:17:23 AM


Document Has Been Signed on 01/12/2024 10:17 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SAN MARCOS COTTAGEFACILITY NUMBER:
374601655
ADMINISTRATOR:BILJANA RIBICHFACILITY TYPE:
740
ADDRESS:1326 GRANITE ROADTELEPHONE:
(760) 891-0328
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:6CENSUS: 4DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:ADMINISTRATOR, BILJANA RIBICHTIME COMPLETED:
10:19 AM
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On January 12, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Administrator, Biljana Ribich. The facility file review was conducted in the office and additional forms were reviewed and requested on site.

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 1326 Granite Rd. San Marcos, CA. 92069. Physical Plant: The facility phone number is (760) 891-0328 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 currently 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 "Personal Rights" and the Ombudsman 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 and it was locked and inaccessible to residents in care. Medications: were reviewed, locked and inaccessible to residents, and there was a 30 day supply. The overall facility is clean, the furniture is in good condition. The facility heating system 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, two staff at the time of this visit, and two Hospice workers. Records Review: The LPA reviewed four resident files, and two staff files, and conducted two staff interviews, and no resident interviews due to the residents being on Hospice or sleeping. Previous Community Care Licensing forms were reviewed. 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, Ribich Biljana.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
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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