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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602645
Report Date: 08/06/2021
Date Signed: 08/06/2021 04:13:22 PM

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:BUENA CREEK RESIDENTIAL CAREFACILITY NUMBER:
374602645
ADMINISTRATOR:ILICH, VESNAFACILITY TYPE:
740
ADDRESS:3008 BUENA CREEK ROADTELEPHONE:
(760) 295-3630
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 6DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Vesna Ilich, LicenseeTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Maria Encomienda, Caregiver and Licensee, Vesna Ilich, later arrived at the facility. LPA met with Vesna Ilich, Licensee, and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA, accompanied by Vesna Ilich, Licensee, conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures/ for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Vesna Ilich, Licensee. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Licensee Ilich at the conclusion of the visit. LPA requested Licensee to send LPA an electronic message reply confirming receipt of these documents.

During the inspection, Licensee Ilich submitted a current Designation of Administrative Responsibility LIC 308 and the Emergency Disaster Plan LIC 610-E is current. LPA requested Licensee to submit a current Personnel Report LIC 500 to the licensing office within 10 business days. Form(s) available at www.ccld.ca.gov.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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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