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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603683
Report Date: 02/23/2023
Date Signed: 02/23/2023 02:13:39 PM


Document Has Been Signed on 02/23/2023 02:13 PM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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:
02/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Smilja MilosavljevicTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct an investigation into complaint #18-AS-20230217085412. This report was created to document deficiencies observed during the time of the visit. LPA met with the Administrator, Smilja Milosavljevic, who was informed of the purpose of the visit.

LPA also reviewed the file for Resident #1 (R1) and found that preplacement assessment was not conducted for the resident. LPA will document deficiency for this along with plan of correction.

An exit interview was conducted where this report along with LIC 809_D pages and appeal rights were reviewed and provided to Administrator, Smilja Milosavljevic.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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Document Has Been Signed on 02/23/2023 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: BREEZE HILL CARE
FACILITY NUMBER: 374603683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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Type B
03/02/2023
Section Cited

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(c) Prior to admission...(1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition...evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.
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The licensee agreed to send a self certified statement, signed, stating that the licensee has read and reviewed the section cited here. This shall be sent to the LPA by the POC due date.
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This requirment was not met as evidenced by: Based on interview and records review it was found that R1 did not have a preadmission appraisal conducted prior to admission. This poses a potential health, saftey, or persoanl rights risk to resident in care.
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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) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2