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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604081
Report Date: 08/22/2026
Date Signed: 08/22/2026 05:13:59 PM

Document Has Been Signed on 08/22/2026 05:13 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:NORTH LA COSTA ASSISTED LIVING, LLCFACILITY NUMBER:
374604081
ADMINISTRATOR/
DIRECTOR:		BOSKOSKI, DEJANFACILITY TYPE:
740
ADDRESS:7623 PRIMAVERA WAYTELEPHONE:
(760) 632-7290
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY: 6CENSUS: 4DATE:
08/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:18 PM
MET WITH:Licensee/Administrator Dejan BoskoskiTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Licensee Dejan Boskoski. The facility's license shows a maximum capacity of 6 non-ambulatory residents. D

LPA and Licensee Dejan Boskoski toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. No pools or bodies of water exist on the premises. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. Confidential records were stored in locked areas.

(Continued on LIC809C)

Simon Jacob
Amy Rodgers
DATE: 08/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/22/2026 05:13 PM - It Cannot Be Edited


Created By: Amy Rodgers On 08/22/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NORTH LA COSTA ASSISTED LIVING, LLC
FACILITY NUMBER: 374604081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 4 of 4 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2026
Plan of Correction
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LPA had Staff #1 lock medication in cabinet and LIcensee agrees to conduct outside source training to all staff and themselves regarding medciation storage.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2026 05:13 PM - It Cannot Be Edited


Created By: Amy Rodgers On 08/22/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NORTH LA COSTA ASSISTED LIVING, LLC
FACILITY NUMBER: 374604081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 4 of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2026
Plan of Correction
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Licensee will immediately discontinue the practice of pre-pouring medications. Licensee will retrain all staff responsible for medication assistance and medication handling, ensuring medications are dispensed only from the original pharmacy container at the time of administration. Licensee will submit proof of staff retraining to LPA by the POC.
Type B
Section Cited
HSC
1569.695(e)(3)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview , the licensee did not comply with the section cited above in 4 of 4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2026
Plan of Correction
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Licensee will create and maintain a medication list for all residents with centrally stored medications, as required by HSC 1569.695(e)(3). Licensee will update resident files for the four affected residents. Licensee will submit copies of the completed medication lists to LPA by the POC Date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: NORTH LA COSTA ASSISTED LIVING, LLC
FACILITY NUMBER: 374604081
VISIT DATE: 08/22/2026
NARRATIVE
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During the required visit and LPA made observations and reviewed resident records, medication storage, and staff training. LPA observed five pre poured medication trays on the kitchen counter, and Staff #1 confirmed the medications had been pre poured after administration. Medication review for Residents #1 through #4 showed medications not stored in their original pharmacy containers. No Medication Administration Record (MAR) was present for the facility. Record review found that R1-R4 did not have required centrally stored medication lists, with one resident currently hospitalized. Additionally, Residents #1 and #2 did not have documentation of annual care plan review meetings or annual routine medical visits within the past 12 months.

Deficiencies were cited today per California Code of Regulations, Title 22 (see the attached LIC809-D pages) Plans of Correction were jointly formed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding documentation of PRN medications. (refer to the LIC9102-TV page).

An exit interview was conducted with Licensee Dejan Boskoski, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided..
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Amy Rodgers
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2026
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/22/2026 05:13 PM - It Cannot Be Edited


Created By: Amy Rodgers On 08/22/2026 at 04:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NORTH LA COSTA ASSISTED LIVING, LLC
FACILITY NUMBER: 374604081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2026
Plan of Correction
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Licensee agreed to coordinate with responsible persons (RP) to ensure that R1 and R2 completes their annual routine physical/medical visit. (In cases where the RP refuses the annual visit, Licensee will document such refusal in writing.) Licensee agreed to send proof of completion to LPA, by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2026


LIC809 (FAS) - (06/04)
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