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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603349
Report Date: 09/17/2021
Date Signed: 09/17/2021 05:52:04 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:VISTA VILLAGE CAREFACILITY NUMBER:
374603349
ADMINISTRATOR:DOBRILA MILOSAVLJEVICFACILITY TYPE:
740
ADDRESS:222 WASHINGTON STREETTELEPHONE:
(760) 295-7258
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:12CENSUS: 10DATE:
09/17/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Miljana Vasic, CaregiverTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted a Case Management visit, to conduct an unannounced health and safety check for clients in care. LPA identified herself and was granted entry by Miljana Vasic, Caregiver. LPA met with caregiver Vasic and disclosed the purpose of the visit.

During today's visit, LPA toured the facility, spoke with staff and clients, and reviewed and obtained client records maintained by the facility. No immediate health or safety concerns were observed, but a potential risk was observed and cited for a deficiency during today’s visit. A plan of correction was jointly developed.

An exit interview was conducted with Miljana Vasic, caregiver and a copy of the report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Dobrila Milosavljev, Licensee via email. An electronic email receipt confirms the documents were received.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VISTA VILLAGE CARE
FACILITY NUMBER: 374603349
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited

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87507 Admission Agreement - Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. This requirement was not met as evidence by:
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Based on staff interview and documentations reviewed which poses a potential risk for one out of ten residents
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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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
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