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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602565
Report Date: 09/06/2023
Date Signed: 09/06/2023 01:27:37 PM


Document Has Been Signed on 09/06/2023 01:27 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:AVOCADO CREEKFACILITY NUMBER:
374602565
ADMINISTRATOR:MARIJA BANOVICFACILITY TYPE:
740
ADDRESS:1080 AVOCADO AVETELEPHONE:
(760) 822-5860
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:12CENSUS: 9DATE:
09/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator Marija Banovic TIME COMPLETED:
01:45 PM
NARRATIVE
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On 9/6/2023, Licensing Program Analyst (LPA) Janette Romero conducted a case management visit to address a deficiency observed during investigation of complaint control #18-AS-20230901085939. LPA met with Administrator Marija Banovic who was informed of the purpose of the visit.

During LPA's visit at the facility on 9/6/2023, LPA reviewed staff records and noted that the CPR/First Aid certification for Staff #1 and Staff #2 expired on 3/9/2023. As a result, LPA issued a deficiency faulting the facility.

An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Banovic along with a Confidential Names List (LIC811), LIC809-D, and Appeal Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/06/2023 01:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: AVOCADO CREEK
FACILITY NUMBER: 374602565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
87411(c)(1)

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87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement was not met as evidenced by:
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Licensee stated CPR/First Aid certificate for staff will be completed on 9/6/2023. Proof of correction will be submitted to CCLD via fax by close of business on POC due date.
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Records reviewed revealed that the CPR/First Aid certification for Staff #1 and Staff #2 expired on 3/9/2023. This poses a potential health and safety risk to residents 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2