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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604834
Report Date: 11/19/2025
Date Signed: 11/20/2025 09:57:25 AM

Document Has Been Signed on 11/20/2025 09:57 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SUMMER PLACEFACILITY NUMBER:
374604834
ADMINISTRATOR/
DIRECTOR:		LEKOVIC, DRAGANAFACILITY TYPE:
740
ADDRESS:1739 SUMMER PLACE DRTELEPHONE:
(760) 402-4282
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 10CENSUS: 10DATE:
11/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Caregiver Nita PabustanTIME VISIT/
INSPECTION COMPLETED:
04:58 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Nita Pabustan. LPA also spoke with Administrators Alex Boskoski and Dragana Lekovic over the phone.

During a facility tour, LPA observed resident records containing medication information stored underneath a table, easily accessible. These records were not secured or safeguarded to protect the confidentiality of their contents.

During a record review of Resident #1 files (R1) [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] it was revealed that there were no previous records for R1's centrally stored medication prior to 10/20/25. Per Admission's Agreement, R1 was admitted to the facility 4/26/25.

During interviews with staff, it was revealed that R1 is currently at the hospital. LPA also reviewed R1's records that indicated at least two other prior hospital visits. LPA reviewed the Department's internal database of reports received from facilities which revealed that the Licensee did not submit any Unusual Incident/Injury Reports (LIC 624) to the Department of these incidences per reporting requirements.

Three deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with Administrators. An exit interview was conducted with Caregiver Nita Pabustan, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Angelica Boyles
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/20/2025 09:57 AM - It Cannot Be Edited


Created By: Angelica Boyles On 11/19/2025 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUMMER PLACE
FACILITY NUMBER: 374604834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2025
Section Cited
CCR
87506(c)(1)

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87506 Resident Records(c)All information and records...shall be confidential(1)The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents…
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Caregiver immediately relocated resdident records in a locked and secured closet. Thereofore, this deficiency has been cleared.
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This requirement has not been met as evidenced by: Based on LPA observations, licensee did not ensure 10 of 10 resident records were not safegaurded. This posed a potential personal rights risk to persons in care.
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Type B
12/04/2025
Section Cited
CCR87465(h)(6)

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87465 Incidental Medical and Dental Care(h)The following...shall apply...(6)The licensee shall be responsible for assuring that a record of centrally stored...medications for each resident is maintained for at least one year
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Licensee and staff will conduct a training reviewing Incidental Medical and Dental Care regulation and submit proof of training to LPA by POC due date.
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This requirment has not been met as evidenced by:Based on records review licensee did not keep proper medication record for 1 of 10 resdients prior to 10/30/25. This posed a potential 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/20/2025 09:57 AM - It Cannot Be Edited


Created By: Angelica Boyles On 11/19/2025 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUMMER PLACE
FACILITY NUMBER: 374604834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2025
Section Cited
CCR
87211(a)(10(D)

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87211 Reporting Requirements(a)Each licensee shall furnish to the licensing agency such reports...(1)A written report shall be submitted to the licensing agency ....(D)Any incident which threatens the welfare, safety or health of any resident...
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Licensee and staff will conduct a training reviewing Reporting Requirements and submit proof of training to LPA by POC date.
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This requirment has not been met as evidenced by: Staff interviews and records review revealed that Licensee did not submit written reports for 1 of 10 resdients when hospitalized. This poses a potnetial risk to 1 of 10 resdients 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2025


LIC809 (FAS) - (06/04)
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