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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603096
Report Date: 02/10/2023
Date Signed: 02/10/2023 02:19:09 PM


Document Has Been Signed on 02/10/2023 02:19 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:LA COSTA ELDER CAREFACILITY NUMBER:
374603096
ADMINISTRATOR:JASNA POPOVICH/VLADA SUBOTFACILITY TYPE:
740
ADDRESS:2641 ABEDUL STREETTELEPHONE:
(760) 448-5686
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:6CENSUS: 4DATE:
02/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Staff Manuel Jadelco and Manager David SwagertyTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Staff Manuel Jadelco. Manager David Swagerty also joined for a portion of the visit via phone.

Today's visit was in response to Resident #1 (R1) moving out from the facility on 01/31/2023, which licensee self-reported to the San Diego Regional Office on 02/01/2023 [see LIC 811 Confidential Names List for a description of R1]. LPA briefly toured the facility, collected records, interviewed staff, and provided technical assistance. CCLD also interviewed outside sources. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Jadelco, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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