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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602012
Report Date: 02/17/2022
Date Signed: 02/18/2022 07:38:25 AM

Document Has Been Signed on 02/18/2022 07:38 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
374602012
ADMINISTRATOR:MIRJANA BUJOSEVICFACILITY TYPE:
740
ADDRESS:2042 N. NUTMEG STTELEPHONE:
(760) 294-1655
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 0DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Administrator Mirjana BujosevicTIME COMPLETED:
10:15 AM
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On 2/17/2022, at 9:08 a.m., Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required 1 - Year Visit. LPA was greeted by Licensee, Mirjana Bujosevic, identified himself, and discussed the purpose of the visit.

LPA conducted a tour of the facility with the Licensee, observed the facility does not have any residents in care, and is in the process of being remodeled. LPA reviewed the infection control tool with administrator, and the facility's implementation of their COVID-19 Mitigation Plan (LIC 808). In accordance with the Department’s Infection Control program, LPA provided technical assistance and signs to be posted throughout the facility. Licensee will notify the LPA when a new resident is admitted to the facility.

No deficiencies were cited on today's visit. An exit interview was conducted with Administrator, Mirjana Bujosevic, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A read receipt email confirms the receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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