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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604348
Report Date: 12/08/2023
Date Signed: 12/08/2023 01:02:02 PM

Document Has Been Signed on 12/08/2023 01:02 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:UTAH FACILITY CAREFACILITY NUMBER:
374604348
ADMINISTRATOR:ROKSANDIC, RADAFACILITY TYPE:
735
ADDRESS:662 UTAH WAYTELEPHONE:
(442) 777-2024
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 6DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:ADMINISTRATOR, DRAGAN ROKSANDICTIME COMPLETED:
01:08 PM
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On December 08, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Administrator, Dragan. The LPA introduced herself and stated the purpose of the visit.

LPA Mixson toured the facility along with the Administrator and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home, located at 662 Utah Way, Escondido, CA. 92025. Physical Plant: The facility phone number is (442) 777-2024 and is operable currently at the time of this visit. The LPA observed the residents bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected facility bathrooms, and the hot water temperature was tested and tested within regulations. The bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something" and the "Personal Rights" postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the resident and staff files and they were locked and inaccessible to residents in care. Medications: were locked and inaccessible to residents and arrive in bubble packs, with a 30 day supply. The overall facility is clean, the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision Facility has sufficient staff, three at the time of this visit, and the residents are in community at the day program. Records Review: The LPA reviewed six resident files, and two staff files. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted and a copy of this report was given to the Administrator, Dragan Roksandic.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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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