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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603683
Report Date: 12/15/2021
Date Signed: 12/16/2021 09:07:17 AM

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:BREEZE HILL CAREFACILITY NUMBER:
374603683
ADMINISTRATOR:SMILJA MILOSAVLJEVICFACILITY TYPE:
740
ADDRESS:799 MARSOPA DRIVETELEPHONE:
(760) 631-0267
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:6CENSUS: 6DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Smilja Milosavljevic, LicenseeTIME COMPLETED:
11:45 AM
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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 Evangeline Bartolazo, Caregiver. LPA met with Caregiver Bartolazo and discussed the purpose of today’s visit. Licensee Smilja Milosavljevic later arrived and joined the inspection.

A tour of the facility was conducted inside and out. LPA, accompanied by Caregiver and Licensee 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 Licensee Milosavljevic. A copy of this report, along with the Applicant/Licensee Rights (01/2016) was emailed to Licensee 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.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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