<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604081
Report Date: 08/11/2022
Date Signed: 08/11/2022 11:01:09 AM


Document Has Been Signed on 08/11/2022 11:01 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: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:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Caregiver, Dianna Cisneros and Administrator, Dejan BoskoskiTIME COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. LPA was greeted at the front entrance by Caregiver, Nareyda Ledesma and granted entry after identifying herself. LPA discussed the purpose of the visit. Administrator, Dejan Boskoski arrived during the visit. This facility serves six (6) elderly residents ages 60 and above; all of whom are non-ambulatory. Facility has a hospice waiver for four.

During today's visit, LPA toured the facility with Caregiver, Dianna Cisneros, and verified compliance with infection control practices. LPA and Administrator, Dejan Boskoski reviewed the facility’s COVID-19 Mitigation and Infection Control Plan. LPA observed one central entry point; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, cough/sneeze etiquette; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE and disinfectants.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Administrator, Boskoski and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided at the facility.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1