374604541-7-21-2023-18-AS-CGOH-CTXQ4V-20230721115059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604541
Report Date: 07/21/2023
Date Signed: 07/21/2023 11:51:09 AM

Document Has Been Signed on 07/21/2023 11:51 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GOLDEN RETREAT		FACILITY NUMBER:	374604541
ADMINISTRATOR:	BOSKOSKI, ALEKSANDAR		FACILITY TYPE:	740
ADDRESS:	1119 WARMLANDS AVE		TELEPHONE:	(760) 521-0303
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	6	CENSUS: 6	DATE:	07/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Aleksandar Boskoski		TIME COMPLETED:	11:51 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cheryl Goodrich conducted an unannounced annual visit. LPA met with the Administrator Aleksandar Boskoski at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility follows California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) non-ambulatory residents of which one (1) may be bedridden in room # 3 and Hospice Waiver for # 4. Facility has two (2) residents on hospice. Physical Plant: front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; doorway alarms were in working order; facility temperature read at 74 degrees; residents' main restroom water temperature read at 118.3 degrees; there were no bodies of water on premises. There are 6 bedrooms and three bathrooms for the residents. There is one bedroom for staff. There was sufficient lighting and mattress pads in all the residents' bedrooms. The fire alarm and smoke carbon monoxide detectors were in working order. Facility does not house firearms and/or ammunition on grounds. Food Services: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents. There is emergency food supply available for all residents and staff.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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 4

Document Has Been Signed on 07/21/2023 11:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN RETREAT	FACILITY NUMBER: 374604541
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of fire drill log and the Administrator's admission, the licensee did not comply with the section cited above in 1 out of 2 fire drills which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	The Administrator states that he will continue to plan each quarter to conduct a fire drill with staff. The Administrator will use his cell phone to place reminders of when he conducts the fire drills.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN RETREAT	FACILITY NUMBER: 374604541
	VISIT DATE: 07/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Medication/Facility Records: Medications were observed to be labeled and in a locked place that is inaccessible to residents. All staff subject to a criminal record review obtained fingerprint clearance and/or an exemption. Staff responsible for direct care and supervision have current First Aid / CPR training. The Administrator has completed a written admission agreement, current medical assessment and needs and service plan with each resident. Waivers are in place and meet said terms. Administrator handles no resident cash resources. Administrator Certificates for both Aleksandar Boskoski and Dragana Lekovich is current and will expire on 09/04/2024.
Items Discussed: The Administrator did not complete the fire drill for the second quarter, as evidenced by the fire drill log and by the Administrator’s admission. The facility has not been documenting the date and time PRN medications were given to the residents.
Summary: Based on today's visit, one deficiency was given and a technical violation. An exit interview was conducted with Administrator Aleksandar Boskoski and a copy of this report was printed Signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4