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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601999
Report Date: 12/19/2022
Date Signed: 12/19/2022 12:49:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2021 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20211215100327
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:
12/19/2022
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Marko KolomijcevTIME COMPLETED:
12:59 PM
ALLEGATION(S):
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-Licensee is prohibiting visitors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Administrator Marko Kolomijcev and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA interviews with facility staff and resident.

It was alleged that the facility was prohibiting visitors. Interview with Administrator revealed during the month of December 2021 the facility had it's first covid outbreak with approxiamtely three covid positive residents. The administrator stated that the facility was "completely shut down" and was not allowing visitors inside the facility for approximately one week. The Administrator further stated that during this time period the facility did allow "window visits" as well as virtual visits including facetime.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 08-AS-20211215100327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 RCFE
FACILITY NUMBER: 374601999
VISIT DATE: 12/19/2022
NARRATIVE
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Interview with Licensee revealed the facility had three to four covid positive residents in the month of December 2021. The licensee recalls "big confusion" during that time period in regards to Covid-19. The licensee further stated that facility staff did not allow visitors inside the facility for approximately one week in December 2021.

Based upon staff interviews, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22.

An exit interview was conducted with Marko Kolomijcev and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Marko Kolomijcev whose signature below confirms receipt of documents.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20211215100327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 RCFE
FACILITY NUMBER: 374601999
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
12/27/2022
Section Cited
CCR
87468.1(a)(11)
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To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.This requirement has not been met as evidenced by:
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Licensee has resumed normal visits at the facility, Licensee will conduct a staff inservice regarding visiting protocol.
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Based on staff interview the licensee did not allow residents to have their visitors...permitted to visit privately during reasonable hours and without prior notice, 5 in 5 of [5] persons in care. which posed a potential Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2021 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20211215100327

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:
12/19/2022
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Marko KolomijcevTIME COMPLETED:
12:59 PM
ALLEGATION(S):
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Designated staff is working with both positive COVID-19 residents and negative residents without precautions.

Facility telephone is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Administrator Marko Kolomijcev and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA direct observation, records review, and interviews.

It was alleged that designated staff was working with both positive COVID-19 residents and negative residents without precautions. Staff Interviews revealed during the month of December 2021 one specific caregiver was dedicated to working with covid positve residents only and this caregiver did not work with covid negative residents during that time period. Interview with Administrator revealed that during the covid outbreak in December 2021, the facility had a specific staff member that worked only with covid positive residents and all staff were required to properly use personal protective equipment( PPE ) at all times.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20211215100327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 RCFE
FACILITY NUMBER: 374601999
VISIT DATE: 12/19/2022
NARRATIVE
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Interview with Licensee revealed the staff member that worked directly with the covid positive residents during the month of December 2021, was also covid positive. The licensee further stated that their was always two caregivers on duty and proper PPE protocol was always followed during the covid outbreak.

It was alleged that the facility telephone was in disrepair. On December 21, 2021 LPA Serrano conducted an unannounced visit to the facility and verified that the facility phone had a dial tone and was working appropriately. LPA Serrano also called the facility at a later time and the phone call was answered by facility staff.

Based on LPA interviews and LPA observation, we have found that the preponderance of the evidence standard has not been met, therefore, the allegations are found to be unsubstantiated.

An exit interview was conducted with Marko Kolomijcev and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Marko Kolomijcev whose signature below confirms receipt of documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5