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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604081
Report Date: 11/29/2022
Date Signed: 11/29/2022 11:08:38 AM

Unsubstantiated


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
02/18/2022 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20220218120802
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: 6DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Dejan BoskoskiTIME COMPLETED:
11:14 AM
ALLEGATION(S):
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Facility did not inform emergency contacts that the resident passed away.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Administrator Dejan Boskoski and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA direct observation, records review, and interviews.

In response to the allegation, it was alleged that Facilty did not inform emergency contacts that the resident passed away (R1) [an LIC 811 Confidential Names List was provided to the facility representative to identify the resident.] Records review revealed that on February 8, 2022 emergency services were called to pick up R1 from the facility due to R1 not responding as usual. R1 was admitted to the hospital that same day. On February 9, 2022 the hospital notified R1's responsible party that the resident passed away. R1's responsible party then notified the facility of the death.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 08-AS-20220218120802
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: NORTH LA COSTA ASSISTED LIVING, LLC
FACILITY NUMBER: 374604081
VISIT DATE: 11/29/2022
NARRATIVE
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Records review further revealed only one contact name was listed for R1 which was their responsible party on file.

Interview with responsible party (RP) on file revealed immediately after R1's death they notified the only family member they had documented on their contact list and advised them of the death.

Interview with Administrator revealed R1 was admitted to the facility over seven years ago by R1's responsible party. R1's responsible party advised the Administrator that R1 had one next of kin. During R1's stay at the facility, R1 did not have any visits from any friends or family. Administrator stated they attempted to notify R1's next of kin immediately after R1's death, but they could not reach them. Administrator further stated that R1's responsible party stated they would handle all of R1's affairs after R1 passed away.

Based on LPA interviews and review of facility records, we have found that the preponderance of the evidence standard has not been met, therefore, the allegation is found to be unsubstantiated.

An exit interview was conducted with Dejan Boskoski and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Dejan Boskoski whose signature below confirms receipt of documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2