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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602012
Report Date: 03/01/2024
Date Signed: 03/01/2024 03:11:18 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/01/2024 03:11 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
374602012
ADMINISTRATOR:MIRJANA BUJOSEVICFACILITY TYPE:
740
ADDRESS:2042 N. NUTMEG STTELEPHONE:
(760) 294-1655
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 0DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Mirjana Bujosevic, LicenseeTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived at the facility unannounced to conduct a annual visit. LPA was met by Licensee, Mirjana Bujosevic and explained the purpose of the visit.

Licensee informed LPA Shaw Ross that the facility does not have any residents in care due to extensive remodeling is still underway. LPA Shaw Ross toured the facility inside and outside and noted remodeling of flooring, kitchen and garage were still underway. LPA Shaw Ross observed required signs posted throughout the facility, appropriate furnishings still in place in all rooms, kitchen supplies, linen and toiletries. The backyard appeared well-kept with a newly built gazebo. Licensee will notify the Department when remodeling is completed and new residents are admitted. Annual Dues were paid on 2/24/2024.

No deficiencies were cited on today's visit. An exit interview was conducted with Administrator, Mirjana Bujosevic, and a copy of this was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024
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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