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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604541
Report Date: 04/28/2022
Date Signed: 04/28/2022 10:39:04 AM


Document Has Been Signed on 04/28/2022 10:39 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:GOLDEN RETREATFACILITY NUMBER:
374604541
ADMINISTRATOR:BOSKOSKI, ALEKSANDARFACILITY TYPE:
740
ADDRESS:1119 WARMLANDS AVETELEPHONE:
(760) 521-0303
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: DATE:
04/28/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Aleksandar Boskoski, Administrator/LLC Member; Dragana Lekovic, Administrator/Managing MemberTIME COMPLETED:
10:21 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census: 4
COMP II Participants: Aleksandar Boskoski, Administrator/LLC Member; Dragana Lekovic, Administrator/Managing Member
Interview Method: Telephone interview

On 4/28/22, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Anna BarriosTELEPHONE: (916) 651-7817
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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