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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603672
Report Date: 12/14/2021
Date Signed: 12/15/2021 08:16:45 AM

Document Has Been Signed on 12/15/2021 08:16 AM - 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:POMELO SENIOR CAREFACILITY NUMBER:
374603672
ADMINISTRATOR:MILIJANA MILOSAVLJEVICFACILITY TYPE:
740
ADDRESS:680 POMELO DRIVETELEPHONE:
(760) 842-1753
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY: 6CENSUS: 5DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marija Nikolic, CaregiverTIME COMPLETED:
03:30 PM
NARRATIVE
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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 Marija Nikolic, Caregiver. LPA met with Caregiver Nikolic and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA, accompanied by Caregiver 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; postings regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; testing plan and procedures was discussed; 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 Caregiver. A copy of this report, along with the Applicant/Licensee Rights (01/2016) was emailed to Milijana Milosavljevic, at the conclusion of the visit. LPA requested Licensee to send LPA an electronic message reply confirming receipt of these documents.

LPA requested Licensee to submit a current Personnel Report LIC 500, Designation of Administrative Responsibility LIC 308 and an Emergency Disaster Plan LIC 610-E to the Licensing office within 10-days of this report. Forms are available at www.ccld.ca.gov.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2021
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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