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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604113
Report Date: 09/22/2026
Date Signed: 09/24/2026 08:42:30 AM

Document Has Been Signed on 09/24/2026 08:42 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:LA COSTA VILLASFACILITY NUMBER:
374604113
ADMINISTRATOR/
DIRECTOR:		LEKOVIC,DRAGANAFACILITY TYPE:
740
ADDRESS:7619 PRIMAVERA WAYTELEPHONE:
(760) 521-0303
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY: 3CENSUS: 3DATE:
09/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:18 PM
MET WITH:Caregiver Eva Vasquez Mendez and Administrator Dragana LekovicTIME VISIT/
INSPECTION COMPLETED:
07:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA met with an individual at the front porch (identified as S1) who called over a staff member who then met with LPA. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to caregiver Eva Vasquez Mendez. The facility's license shows a maximum capacity of three (3) non-ambulatory residents. Additionally, the facility is approved for three (3) hospice waivers. During today’s inspection there were three (3) residents in care. Administrator Dragana Lekovic arrived shortly after to join LPA.

Upon review of the facility's association roster, LPA noted that S1 was not associated to the facility. Per interview with staff members, S1 is a relative of Administrator Lekovic and resides on the property and is not a staff member, or an admitted resident. LPA explained that S1 would still require to be associated to the facility, per regulation. Review of the Guardian background check database revealed S1 did have an eligible background clearance, just that they were not associated to the facility.

One type A Deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached LIC 809-D for S1 residing at the facility without having their clearance associated to the facility. In addition, a Civil Penalty is being assessed for the total amount of $500.00. Details are noted on the attached LIC 421BG form. The facility was able to submit an LIC 9182 request to the Regional Office to associate S1 during the visit.

[Continued on LIC 809-C]
Sabel Martinez
Arian Golbakhsh
DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2026
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 7
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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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: LA COSTA VILLAS
FACILITY NUMBER: 374604113
VISIT DATE: 09/22/2026
NARRATIVE
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[Continued from LIC 809]

LPA and Administrator Lekovic toured the interior and exterior of the facility and inspected each room. Required licensing postings were observed in visible areas of the facility. 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. Hot water temperature at taps accessible to clients were not compliant: the common sink by the front door was 99.9F and a Technical Violation (TV) was issued. Extra linens and hygiene supplies were present.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. As LPA was being shown the garage, which was accessible to residents, LPA observed a jug of laundry detergent present in the garage. Staff immediately moved the item to secured storage. One Type A Deficiency was issued for the accessible chemical/toxic item and details are noted on the attached LIC 809-D page.

LPA observed a swimming pool in the backyard, which had a surrounding fence, as required. However, LPA observed that the access gate was unlocked. Administrator Lekovic immediately locked the gate. One Type A Deficiency was issued for the accessible body of water and details are noted on the attached LIC 809-D page. As accessible bodies of water fall under the category of Zero Tolerance Civil Penalties, a Civil Penalty in the amount of $500.00 was issued.

Per Administrator Lekovic, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for July 2026. Medications were labeled, as required, and stored in locked areas. As LPA was shown a medication record log, pulled from a table cabinet, LPA observed a loose pill. LPA requested Administrator Lekovic to properly dispose of the medication, which they did. One Type B citation was issued for the accessible medication. First aid kit was complete and readily accessible, aside from a first aid manual. A Technical Violation (TV) was issued. Required licensing postings were observed in visible areas of the facility.

[Continued on LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/24/2026 08:42 AM - It Cannot Be Edited


Created By: Arian Golbakhsh On 09/22/2026 at 05:28 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: LA COSTA VILLAS
FACILITY NUMBER: 374604113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
"All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or"

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review and interview, the licensee did not comply with the section cited above in ensuring an individual had their background clearance associated to the facility prior to residing on the property, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/23/2026
Plan of Correction
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Licensee submitted an LIC 9182 request to the Regional Office for the association of S1. Licensee will conduct review of regulation 87355 and submit proof to LPA by 10/6/26.
Type A
Section Cited
CCR
87307(e)(2)(A)
"The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (2) Fishponds, wading pools, hot tubs, swimming pools, or similar larger bodies of water. (A) The licensee shall ensure that the bodies of water specified above are inaccessible through fencing, covering, or other means when not in active use by residents."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in ensuring the pool gate was locked, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/23/2026
Plan of Correction
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Licensee will conduct an in-service training with staff on accessible bodies of water and submit proof to LPA by 10/6/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
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: LA COSTA VILLAS
FACILITY NUMBER: 374604113
VISIT DATE: 09/22/2026
NARRATIVE
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[Continued from LIC 809-C]

Due to time constraints, LPA was unable to conduct file review of facility records. An additional visit on a subsequent date is required to complete the annual inspection.

Four (4) deficiencies were cited during today's visit, along with two (2) Technical Violations (TVs). Civil Penalties issued today total $1,000.00. An exit interview was conducted with Administrator Lekovic to whom a copy of this report, the LIC 421BG, LIC 421IM, two (2) LIC 9102 (TV forms), and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/24/2026 08:42 AM - It Cannot Be Edited


Created By: Arian Golbakhsh On 09/22/2026 at 06:04 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: LA COSTA VILLAS
FACILITY NUMBER: 374604113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(a): "Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage."

This requirement is not met as evidenced by
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in ensuring toxic/chemical items were in secured storage and inaccessible to residents, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/23/2026
Plan of Correction
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Staff immediately removed the chemical item to secured storage. Licensee will conduct an in-service training with staff on regulation 87309 and proper chemical storage procedures. Licensee will submit proof to LPA by 10/6/26.
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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/24/2026 08:42 AM - It Cannot Be Edited


Created By: Arian Golbakhsh On 09/22/2026 at 06:12 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: LA COSTA VILLAS
FACILITY NUMBER: 374604113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
87465(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 LPA observation, the licensee did not comply with the section cited above in ensuring medications which are centrally stored were inaccesible to residents, which posed a potential health and safety risk to persons in care.
POC Due Date: 10/06/2026
Plan of Correction
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Licensee will conduct review of regulation 87465 and conduct an in-service with staff on proper medication storage and access. Licensee will submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2026


LIC809 (FAS) - (06/04)
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