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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604113
Report Date: 09/29/2021
Date Signed: 09/29/2021 04:46:58 PM

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:LA COSTA VILLASFACILITY NUMBER:
374604113
ADMINISTRATOR:LEKOVIC,DRAGANAFACILITY TYPE:
740
ADDRESS:7619 PRIMAVERA WAYTELEPHONE:
(760) 521-0303
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:3CENSUS: 3DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Licensee Dragana LekovicTIME COMPLETED:
03:20 PM
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Licensing Program Manager (LPM) John Rante and Licensing Program Analyst Ramon Serrano, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPM and LPA met with Caregiver Marisol Rodriguez. Licensee Dragana Lekovic arrived and we discussed the purpose of the visit. All staff who interacted with the LPM and LPA, have a current criminal record clearance.

LPM and LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPM and LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

The Licensee will be provided a copy of her appeal rights (LIC9058 01/16). An exit interview was conducted and a copy of this report will be emailed to the Licensee with an electronic read receipt as confirmation of documents.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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