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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604081
Report Date: 03/02/2021
Date Signed: 03/03/2021 08:57:44 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:NORTH LA COSTA ASSISTED LIVING, LLCFACILITY NUMBER:
374604081
ADMINISTRATOR:BOSKOSKI, DEJANFACILITY TYPE:
740
ADDRESS:7623 PRIMAVERA WAYTELEPHONE:
(760) 632-7290
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:6CENSUS: 5DATE:
03/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Administrator- Dejan BoskoskiTIME COMPLETED:
05:50 PM
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Licensing Program Analyst (LPA), Kristina Ryan, initiated an unannounced case management visit to conduct a health and safety check and review COVID-19 mitigation plan. The virtual visit was conducted via FaceTime due to COVID-19 restrictions. LPA met with Administrator, identified herself, and stated the purpose of the virtual visit.

On March 1, 2021 Administrator, Dejan Boskoski notified Community Care Licensing that the community had a new positive COVID-19 case following COVID-19 testing.

During today's visit, LPA toured the facility and interviewed the Administrator. No deficiencies were issued during this visit.

An exit interview was conducted. A copy of this report and Licensee's Rights (9058 01/16) were provided to the Administrator via electronic mail. An email receipt confirms the acknowledgement of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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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