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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604224
Report Date: 12/10/2021
Date Signed: 12/10/2021 01:44:55 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 COASTAL CAREFACILITY NUMBER:
374604224
ADMINISTRATOR:SUBOTIC, LUKAFACILITY TYPE:
740
ADDRESS:3207 LA COSTA AVENUETELEPHONE:
(760) 707-9192
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:6CENSUS: 4DATE:
12/10/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Luka SuboticTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs), Kayla Hilario and Iby Strong, and County of San Diego Nurse Contractor, Jen West, conducted an on-site visit. LPAs and Nurse identified themselves and discussed the purpose of the visit with Administrator, Luka Subotic.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, screening protocols as well as the use of personal protective equipment. During today's visit, Administrator was interviewed and a walk-though of the facility was conducted. A debriefing was conducted with the Administrator at the conclusion of the visit. No deficiencies were issued today.

An exit interview was conducted with the Administrator and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Licensee via electronic mail. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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