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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603349
Report Date: 03/15/2023
Date Signed: 03/15/2023 11:19:11 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2022 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220316135053
FACILITY NAME:VISTA VILLAGE CAREFACILITY NUMBER:
374603349
ADMINISTRATOR:SMILJA MILOSAVLJEVICFACILITY TYPE:
740
ADDRESS:222 WASHINGTON STREETTELEPHONE:
(760) 295-7258
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:12CENSUS: 8DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Dobrila Milosavjevic, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff gave consent for resident to receive hospice services, and not the POA.
Staff gave and signed resident's DNR consent, and not their POA.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) made an unannounced visit to deliver findings for the allegation(s) noted above. LPA met with Dobrila Milosavjevic, Administrator and explained the purpose of the visit. The investigation consisted of observation, interviews and record review.

Allegation:Staff gave consent for resident to receive hospice services, and not the POA.
LPA reviewed documentation for Resident #1 (R1). R1 was admitted to the facility on 02/26/2019, after having to move from another board and care that closed its doors. R1 signed their admission paperwork identifying them self as the responsible party. However, there is white out of the form, the document looks like it was altered as the lines are cut off, as well as remnants of white out are present, specifically on the responsible person signature section, as well as the date section. Per Dobrila Milosavljevic, Adminstrator , R1 does not have anyone, and that they were admitted to the facility by them self, there have not been any visitors nor phone calls. Rent is supposed to be $2500, but R1 only pays $1200 due to their limited
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20220316135053
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA VILLAGE CARE
FACILITY NUMBER: 374603349
VISIT DATE: 03/15/2023
NARRATIVE
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income. LPA attempted to interview R1 but was unsuccessful, as they fell asleep due to having a headache. Per the hospice care plan R1 is in their end stage of life and has been given six months left to live. Administrator Dobrilla states that R1 had an increase in their needs. R1 allegedly expressed interest in getting placed on hospice due to having limited funds and needing to assistance with their incontinent supplies. Upon further investigation it was revealed that R1 does in fact have a power of attorney. Their name is indicated on a copy R1’s bank statement, as the beneficiary to be paid upon R1’s death. The Administrator Dobrilla denies having knowledge of this information. On R1s Identification and emergency notification form dated 2/26/19, R1 identified them self as the responsible person for financial affairs but does note the nearest living relative listed who is also their Power of Attorney.

Upon further review R1s Physician Orders for Sustaining Treatment (POLST) dated 12/10/21, revealed that Licensee Miliana Vasic signed stating that she was the Legally recognized Decision maker for R1. In addition to signing the POLST Miliana also signed as the emergency management plan identifying herself as the emergency contact for R1. The form is dated the same day as R1 start of service date for hospice. Based on observation, interview and record review, the allegation of Staff gave consent for resident to receive hospice services, and not the POA is SUBSTANTIATED.

Allegation: Staff gave and signed resident's DNR consent, and not their POA.

Regarding the allegation of staff gave and signed residents’ DNR consent and not their POA. A review of R1’s records revealed that R1 is noted to have begun receiving hospice services on 12/10/2021. Additional documentation revealed that R1 signed their original POLST 10/22/2019, their self. Upon further review in R1s file there is an updated POLST, and the Administrator Miliana Vasic did in fact sign the POLST dated 12/10/2021, identifying herself as the Legally recognized Decision nmaker for R1. Therefore, the allegation is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.

An exit interview was conducted and a copy of this report, 9099C, 9099D, and appeal rights were provided to Dobrila Milosavjevic, Administrator.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2022 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220316135053

FACILITY NAME:VISTA VILLAGE CAREFACILITY NUMBER:
374603349
ADMINISTRATOR:SMILJA MILOSAVLJEVICFACILITY TYPE:
740
ADDRESS:222 WASHINGTON STREETTELEPHONE:
(760) 295-7258
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:12CENSUS: 8DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Dobrila Milosavjevic, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff misused resident's finances.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) made an unannounced visit to deliver findings for the allegation(s) noted above. LPA met with Dobrila Milosavjevic, Administrator and explained the purpose of the visit. The investigation consisted of observation, interviews and record review.
Resident #1 (R1) is diagnosed with Alzheimer’s disease, and is noted on their physician’s report of not being able to manage their own cash resources. LPA was provided copies of R1s bank statements and R1 does have a power of attorney that is identified as the individual to be paid upon R1s death. LPA reviewed invoices for R1s incontinent supplies and rent. The checks and deposits match the invoices and receipts provided. R1 should not be managing their own finances as per their physician’s report such as allegedly writing checks for their rent and other items such as hygiene supplies. However, there is not enough evidence to support that staff have misused R1’s finances therefore the allegation is UNUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of this report was provided to Dobrila Milosavjevic, Administrator.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20220316135053
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA VILLAGE CARE
FACILITY NUMBER: 374603349
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2023
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by the Licensee signed and gave consent for R1 to receive services from hospice instead of their POA. This poses a potential personal rights risk to residents in care.
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This Licensee agrees to have a staff training on the role of the responsible party and POA and the importance of including residents responsible party in the plan of care
Proof of POC is to be submitted by 5pm on the due date indicated.
Type B
03/29/2023
Section Cited
HSC
156.153
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156.153 Health and Safety code
(26) To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee. Except as provided for in approved continuing care agreements, a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following:(C) Serve as an agent for a resident under any general or special power of attorney. This requirement is not met as evidenced by the Licensee signed and gave consent for R1s “do not resuscitate”. This poses a potential personal rights risk to residents in care.

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The licensee agrees to conduct a staff training on the POLST form.
Proof of POC is to be submitted by 5pm on the due date indicated.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4