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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604113
Report Date: 09/27/2022
Date Signed: 09/27/2022 01:55:31 PM


Document Has Been Signed on 09/27/2022 01:55 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
SO. CAL AC/SC, 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: 2DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Aleksandar BoskoskiTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nacole Patterson visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Metodija Boskoski, to whom the purpose of the visit was disclosed. Administrator Aleksandar Boskoski arrived at the facility during the visit.

During today's visit, LPA toured the facility and was accompanied by Metodija Boskoski. LPA verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; temperature check initiated at entry for staff, residents, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough/sneeze etiquette, symptom and transmission awareness; face covering worn by staff; hand sanitizer/hand washing stations readily available; available visitation area; emergency agencies’ contact information visible to staff; and an ample supply of cleaning products.

During today’s visit, LPA Patterson discovered that Staff 1 (S1) [LIC 811 Confidential Names List was provided to identify the staff], who was present and observed working at the facility at the time of the visit, had been working in the facility for two (2) days, from 9/26/22 to 9/27/22, without a current criminal background clearance or exemption.

A civil penalty in the amount of $200 was issued on form LIC 421-BG, for allowing a person who is subject to a background check and requires a criminal record clearance to work in the facility without first obtaining required criminal background clearance or exemption. Civil penalties in the amount of $100 per day per citation will continue to accrue until the deficiency is corrected.

A deficiency is cited pursuant to Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D. This report was discussed with Administrator Aleksandar Boskoski. A copy of this report, LIC 421-BG, and licensee appeal rights were provided to him at the conclusion of the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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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Document Has Been Signed on 09/27/2022 01:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: LA COSTA VILLAS
FACILITY NUMBER: 374604113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)


This requirement is not met as evidenced by: 87355(e)(1) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing in a licensed facility: (1) Obtain a California clearance or a criminal record exemption.
Deficient Practice Statement
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Based on LPA observation S1 was observed working at the facility on 9/27/22 as a caregiver without a criminal record clearance. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2022
Plan of Correction
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Licensee will assure that S1 will only return to work at La Costa Villas 374604113 when the fingerprint background clearance has been obtained. A $200 Civil Penalty was assessed. Immediate risk removed.
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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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