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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602634
Report Date: 03/13/2024
Date Signed: 03/13/2024 12:19:36 PM


Document Has Been Signed on 03/13/2024 12:19 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: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: 2DATE:
03/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ADMINISTRATOR LJILJANA ZEZELJTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Administrator Ljiljana Zezelj, to discuss the purpose of the visit. 

Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who suffered a fall with injuries.

LPA interviewed staff, outside sources and collected records. A wellness check was completed; no health or safety issues were identified. No deficiencies were cited or observed on this date. 

An exit interview was conducted with Administrator Ljiljana Zezelj, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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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