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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602012
Report Date: 02/18/2025
Date Signed: 02/18/2025 10:19:56 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/18/2025 10:19 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
374602012
ADMINISTRATOR/
DIRECTOR:		MIRJANA BUJOSEVICFACILITY TYPE:
740
ADDRESS:2042 N. NUTMEG STTELEPHONE:
(760) 294-1655
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 0DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Licensee, Mirjana BujosevicTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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On 2/18/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA phoned Licensee, Mirjana Bujosevic who reported the facility is currently unoccupied as the home's renovations continue. Licensee arrived during the visit to meet with LPA. Licensee reported they have not made any changes to the structure of the facility and all renovations have been superficial including new flooring/carpet, kitchen cabinets, and paint. The facility is licensed to serve six (6) non-ambulatory elderly residents and has an approved hospice waiver for two (2).

LPA toured the facility with Licensee and did not observe any residents in care or evidence to suggest the home is currently occupied. LPA observed the facility has operating utilities along with a working refrigerator. The facility has the required furniture in all rooms and a charged fire extinguisher near the front entrance. No bodies of water were observed in the premises. The facility's annual licensing fees have been paid. Licensee estimated the renovations will be completed by the end of 2025. Licensee reported they will notify the Department when renovations have been completed and they plan to admit new residents. During today's visit, no deficiencies were issued. An exit interview was conducted an a copy of this report was reviewed and provided to Licensee.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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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