374603349-9-7-2021-08-AS-DPOL-C8A368-20211029175754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603349
Report Date: 09/07/2021
Date Signed: 09/07/2021 04:08:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2021 and conducted by Evaluator Carmen Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20210816142111

FACILITY NAME:	VISTA VILLAGE CARE		FACILITY NUMBER:	374603349
ADMINISTRATOR:	DOBRILA MILOSAVLJEVIC		FACILITY TYPE:	740
ADDRESS:	222 WASHINGTON STREET		TELEPHONE:	(760) 295-7258
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	12	CENSUS: 10	DATE:	09/07/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Dobrila Milosavljevic, Licensee		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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- Conduct inimical.

INVESTIGATION FINDINGS:

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Regional Manager (RM) Icela Estrada, Licensing Program Manager (LPM) Denise Powell, and Licensing Program Analyst (LPA) Carmen Lopez conducted an office visit to deliver investigative findings. LPM and LPA met with licensee Dobrila Milosavljevic and explained the purpose of today’s office visit.

It was alleged that the administrator was engaged in conduct that is inimical to the health, morals, welfare, or safety of residents receiving services from the facility. Investigation included interviews and review of documents from outside sources.

Documentation obtained from the U.S. District Court, Southern District of California, Department of Justice--U.S. Attorney’s Office revealed that on July 6, 2021, the United States District Court Southern District of California filed a complaint against Licensee/Administrator Dobrila Milosavljevic charging her with violations of Title 8, U.S.C., Section 1349 - Conspiracy to Commit Wire Fraud.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210816142111

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 09/07/2021

NARRATIVE

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The Department verified Ms. Milosavljevic’s status as the current certified Administrator as well as an active managingmember holding 50% interest of the Limited Liability Company (LLC) listed as the licensee of the facility. During interview with the licensee, she disclosed having “legal trouble” because of her former husband but denied participating in fraud. She advised she would not be able to provide additional information or documentation requested by the Department without speaking to her attorney.

The Department has found there is a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation is substantiated. A deficiency is cited per Title 22, Division 6. Chapter 8 of the California Code of Regulations and is listed on the LIC 9099-D form. This report was discussed with Dobrila Milosavljevic and a Plan of Correction was jointly developed with the Licensee. A copy of this report along with Appeal Rights (01/2016) was provided at the conclusion of today’s meeting. Licensee’s signature on this form acknowledges receipt of these rights.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20210816142111

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/21/2021 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	The department may deny and application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter. Conduct that is inimical to the health, morals, welfare or safety of either an individual in or receiving services from the facility or the people of the State of California.	1 2 3 4 5 6 7	Licensee agreed to appoint new administrator by September 21, 2021 and to submit a change of ownership (CHOW) by September 30, 2021.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee engaged in conduct that is inimical to the health, morals, welfare or safety in 10 of 10 persons in care which posed a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021

LIC9099 (FAS) - (06/04)

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