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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604541
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:47:14 PM


Document Has Been Signed on 04/18/2024 03:47 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 5DATE:
04/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:18 PM
MET WITH:Dragana Radjenovic Lekovic, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George made a case management deficiencies visit. The following deficiencies were observed during LPAs visit to the facility on 4/18/24:

LPA conducted a review of the facility personnel roster and observed Staff #1 (S1) and Staff #2 (S2) to not have obtained proper fingerprint clearance, nor to be associated to the facility. Both staff both were escorted off the premises, an immediate $500 civil penalty is being assessed for both S1 and S2 totaling $1,000.

LPA discussed with Administrator Dragana that both S1 and S2 have to be removed from the schedule until further notice of having the proper fingerprint clearance being obtained.

Based on today's visit a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report, appeal rights, LIC 811, LIC9098 and LIC 421BG was provided to Dragana Radjenovic Lekovic, Administrator.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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 2


Document Has Been Signed on 04/18/2024 03:47 PM - 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GOLDEN RETREAT
FACILITY NUMBER: 374604541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2024
Section Cited
CCR
87355(e)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the
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The Licensee agrees to have S1, S2 obtain proper fingerprint clearance and associate them to the facility. S1 S2 will not work on grounds until proper clearance has been obtained. POC is to be submitted to the department by 5pm on the due date indicated.
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section cited above in 2 out of 2 times as S1, S2 do not have proper fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
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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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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