374602406-1-12-2024-08-AS-DPEA-CZEUUJ-20240112145337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602406
Report Date: 01/12/2024
Date Signed: 01/12/2024 02:53:55 PM

Document Has Been Signed on 01/12/2024 02:53 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	CARLSBAD ELDER CARE		FACILITY NUMBER:	374602406
ADMINISTRATOR:	JASNA POPOVICH		FACILITY TYPE:	740
ADDRESS:	1840 BIENVENIDA CIR		TELEPHONE:	(760) 729-9800
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	6	CENSUS: 6	DATE:	01/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Marko Kolomijcev, Administrator		TIME COMPLETED:	11:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/12/2024, at about 09:17 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Marko Kolomijcev, Administrator and David Swagerty, Co-Administrator. According to the facility’s license, the facility serves six (6) elderly residents, age 60 and above, all of whom may be non-ambulatory. Hospice waiver for two (2) residents granted. On the day of the visit, LPA observed six residents, all non-ambulatory. During the inspection, LPA toured the interior and exterior of the facility and observed each resident’s room. The facility was organized, kempt and in good repair. The facility had no offensive odors. Pathways inside the property were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least two days of perishable food, and at least seven days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per Administrator, Kolomijcev, no firearms or ammunition are kept at the facility. Emergency lighting, and facility telephone were all working. LPA observed carbon monoxide, smoke detectors, and fire extinguishers and all were serviceable and operational. First aid kit(s) were observed. Required licensing postings were observed in visible areas of the facility. Hot water temperatures measured at 107.2 and 107.7 in sinks accessible to residents. Bathroom toilets, sinks and showers were observed to be in good service and operational.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CARLSBAD ELDER CARE	FACILITY NUMBER: 374602406
	VISIT DATE: 01/12/2024

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LPA interviewed residents and reviewed staff and resident records/files. Staff records were reviewed and contained CPR/First Aid certifications, health screenings and fingerprint clearances. LPA interviews did not raise any licensing concerns. The resident files which LPA reviewed contained the required documents. Confidential records were stored in locked areas.

No deficiencies were cited during today's annual inspection.

An exit interview was conducted with Administrator, Kolomijcev to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
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

LIC809 (FAS) - (06/04)

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