<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881440
Report Date: 08/14/2023
Date Signed: 08/14/2023 12:42:16 PM

Document Has Been Signed on 08/14/2023 12:42 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANA'S ELDER CAREFACILITY NUMBER:
371881440
ADMINISTRATOR:SIVCEV, KATARINA-NASTASJAFACILITY TYPE:
740
ADDRESS:1828 PASEO DEL LAGO DRIVETELEPHONE:
(760) 420-0702
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY: 6CENSUS: 0DATE:
08/14/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Any Swagerty, LicenseeTIME COMPLETED:
12:45 PM
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
On 08/14/2023 Licensing Program Analyst (LPA), Jacqueline Shaw Ross, conducted an announced pre-licensing inspection at the facility. The LPA met with Licensee, Any Swagerty. Also present at the facility were Administrator Katarina Sivcev and Licensee’s mother Jasna Popovich.

The application is for a Residential Care Facility for the Elderly (RCFE) for six (6) non-ambulatory residents, of which one (1) may be bedridden and will be in bedroom #5. The facility has an approved Hospice waiver for six (6) hospice residents as of May 17, 2023.

A tour was conducted of the interior and exterior of the facility. The house is a single story with, five (5) bedrooms, two full (2) bathrooms, kitchen, dining area, living room, laundry room, office area, front/backyard area. The outdoor space is suitable for resident use and was observed to be fully fenced with an unlocked gate. The facility has taken extra security measures and has an alarm on all the exit doors. The walkways of the home were observed to be clutter free with no obstructions present. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, shower and tubs have grab bars and non-skid mats. The hot water was tested in one resident bathroom and measured at 109.5 degrees F. Night lights were observed throughout the hallways.

LPA observed food storage and preparation areas and were observed to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. The kitchen was observed to have dishes, silverware and pots and pans in good repair and enough for the capacity. All appliances are clean and are operable.

There is a sufficient supply of linens, towels and personal hygiene items. There is a new first aid kit with a manual; all items were present. CONTINUE ON LIC809-C...
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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 2
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: ANA'S ELDER CARE
FACILITY NUMBER: 371881440
VISIT DATE: 08/14/2023
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
 CONTINUED FROM LIC809...

LPA observed a recreation area with leisure items and activities, which include puzzles for Dementia residents, magazines and newspapers located in the dining area, living room areas.

LPA observed three (3) fully charged fire extinguishers. The smoke alarms and carbon monoxide detectors are all connected were tested and are operable. Medications will be stored and locked in a corner cabinet in the kitchen area. All hazardous materials such as, cleaning and disinfecting supplies, knives, and other sharps are locked and inaccessible to residents. All required forms such as: emergency disaster plan and complaint poster, Administrator Certificate, personal rights, etc. are posted throughout the entrance area, dining and living room areas. LPA observed and tested a washing machine and dryer located in a locked area inaccessible to residents. The garage contained an appropriate supply of emergency food and additional cleaning supplies which are also inaccessible to residents.

Pre-licensing inspection is complete. COMP III was completed prior to the inspection on August 9, 2023. The facility is ready to be licensed.

An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee, Any Swagerty.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2