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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602634
Report Date: 08/14/2022
Date Signed: 08/14/2022 08:36:34 PM


Document Has Been Signed on 08/14/2022 08:36 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:LA COSTA GOLDEN CAREFACILITY NUMBER:
374602634
ADMINISTRATOR:ZEZELJ, LJILJANAFACILITY TYPE:
740
ADDRESS:2830 CAZADERO DRIVETELEPHONE:
(760) 438-8848
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:6CENSUS: 5DATE:
08/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Licensee Ljiljana Zezelj
TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Correia conducted an unannounced annual inspection. LPA identified herself and was greeted and allowed entry to the facility by Caregiver Maria Reyes. LPA met with Licensee Zezelj and explained the purpose of the visit.

LPA conducted a tour of the facility accompanied by Licensee Zezelj, to ensure compliance with the Department’s Infection Control Policy. LPA provided technical assistant and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; A sign-in policy enacted for all visitors; Face coverings worn by staff; Hand sanitizer/hand washing stations readily available; A designated visitation area; Emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.

An exit interview was conducted with Licensee Zezelj to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided. Signature on this form confirms receipt of the reports.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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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