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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604113
Report Date: 06/25/2024
Date Signed: 06/25/2024 02:13:34 PM


Document Has Been Signed on 06/25/2024 02:13 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: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:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver Diana CisnerosTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Nacole Patterson 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 Caregiver Diana Cisneros. The facility's license shows a maximum capacity of three (3) non-ambulatory residents, ages 18-59. During today’s inspection there were three (3) residents in care.

LPA and caregiver Diana Cisneros 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. Medications were labeled, as required, and stored in locked areas. The facility has a pool that was inaccessible to residents with a locked fence. Per caregiver Diana Cisneros, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. During the visit the Administrator scheduled an appointment for the fire extinguisher to be serviced on 6/27/24 and will provide proof to LPA. 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. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.
 
No deficiencies were cited during the inspection. An exit interview was conducted with caregiver Diana Cisneros to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024
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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