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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604512
Report Date: 05/09/2023
Date Signed: 05/09/2023 11:35:37 AM


Document Has Been Signed on 05/09/2023 11:35 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:VISTA VILLAGE CAREFACILITY NUMBER:
374604512
ADMINISTRATOR:MILOSAVLJEVIC, MILIJANAFACILITY TYPE:
740
ADDRESS:222 WASHINGTON STREETTELEPHONE:
(760) 518-5061
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:12CENSUS: 7DATE:
05/09/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Applicant, Milijana MilosavljevicTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an announced visit for the purpose of conducting the prelicensing inspection on 5/9/2023 at 10:11 a.m. LPA met with applicant Miljana Milosavljevic for the visit. The applicant is seeking a change in ownership for an residential care facility for the elderly with a capacity for (12) residents, ages 60 and up. The current licensee, Dobrila Milosavljevic was also present for the visit.

LPA conducted a walk through of the interior and exterior of the facility. The home is a (8) bedroom and (7) bathroom, one story home. No pools or firearms are present at the facility. The fire clearance conducted on 12/14/2023 by City of Vista Fire Department was approved the home for (10) non-ambulatory residents, and (2) bedridden. LPA observed the rooms had the (2) exits that are required and sprinkler system that was newly replaced in February 20,2023. These exits have working alarm systems. The resident bedrooms were observed to had the appropriate linens, furniture such as bed, dresser, closet space, light, night stand and chair. The home has extra linens and bath towel in the hallway which. First aid kit was locked in locked medication cabinet. The facility kitchen has enough pots and pans, cooking utensils, plates and cups for all Residents. The kitchen had the appropriate food items. LPA observed the bathrooms in the facility to have hand hygiene supplies, and personal care items for residents. The laundry room was observed be functional, and the facility possesses cleaning supplies to conduct regular cleaning of the facility. These items are located in the facility locked garage, and under the kitchen sink. The smoke alarms and carbon monoxide detectors were found in working condition. The dining room has enough seating for (6) residents, and the outdoor space has enough seating for (6) residents LPA observed the home has activities for clients to engage in. The land line was observed to be operational (760 295-7258). Kitchen knifes will be kept locked with the in the kitchen.

Per the applicant, component III orientation was attended on May 4, 2023 at the regional office. An exit interview was conducted were this report was reviewed and provided to the applicant, Miljana Milosavljevic.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
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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