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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601999
Report Date: 11/24/2021
Date Signed: 11/24/2021 03:47:34 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:LA COSTA GOLF RCFEFACILITY NUMBER:
374601999
ADMINISTRATOR:JASNA POPOVICHFACILITY TYPE:
740
ADDRESS:2702 LA COSTA AVETELEPHONE:
(760) 944-1900
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:6CENSUS: 5DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:59 AM
MET WITH:Marko KolomijcevTIME COMPLETED:
12:59 PM
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Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Administrator Marko Kolomijcev and discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

The Licensee will be provided a copy of their appeal rights (LIC9058 01/16). An exit interview was conducted with Marko Kolomijcev and a copy of this report will be emailed to the Licensee with an electronic read receipt as confirmation of documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
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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