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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602406
Report Date: 12/09/2024
Date Signed: 12/09/2024 01:37:16 PM

Document Has Been Signed on 12/09/2024 01:37 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CARLSBAD ELDER CAREFACILITY NUMBER:
374602406
ADMINISTRATOR/
DIRECTOR:		JASNA POPOVICHFACILITY TYPE:
740
ADDRESS:1840 BIENVENIDA CIRTELEPHONE:
(760) 729-9800
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 6CENSUS: 5DATE:
12/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Administrator Marco KolomijcevTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Hannah Rodgers and LPA Rebecca Ruiz conducted an unannounced case management visit to cite for a deficiency observed during a previous visit. LPAs introduced themselves, and met with Administrator Marco Kolomijcev. LPA spoke with Administrator David Swagerty via telephone during the visit.

During today’s visit, LPAs observed residents in care. LPAs' observations and information provided by licensee and staff today and during previous visit on 12/5/2024 revealed that Resident 1 (R1) is bedridden and unable to reposition independently. Administrator Kolomijcev was provided with an LIC811 Confidential Names List to identify R1. Review of facility's license and fire clearance revealed that the facility is cleared and licensed for 6 non-ambulatory residents. The facility does not have an approved fire clearance to house a bedridden resident.

Based on this information, a deficiency is being cited Per Title 22, Division 6, Chapter 8 of the
California Code of Regulations and is listed on an LIC 809-D. Additionally, an immediate civil penalty in the amount of $500 is being assessed on an LIC421IM.

An exit interview was conducted with Administrator Kolomijcev, to whom a copy of this report, LIC809-D, LIC811, LIC421IM, and Licensee/Appeal Right (LIC9058), were provided. 
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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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Document Has Been Signed on 12/09/2024 01:37 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Hannah Rodgers On 12/09/2024 at 01:00 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: CARLSBAD ELDER CARE
FACILITY NUMBER: 374602406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/10/2024
Section Cited
CCR
87202(a)(2)

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Fire Clearance... Prior to accepting or
retaining any of the following types of persons, the applicant or licensee shall...obtain an appropriate fire clearance approved by the city, county... fire department... or the State Fire Marshal. (2) Bedridden persons.
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Administrator David Swagerty agreed to work with R1's responsible party to relocate R1 to a sister facility with a bedridden clearance. Administrator agreed to provide the Department with a copy of R1's responsible party written agreement
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This requirement was not met as evidenced by: Based on record review and observations, the licensee did not obtain an approved fire clearance prior to accepting or retaining R1, who is bedridden. This poses an immediate safety risk to 1 of 5 persons in care.
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 for R1's relocation to the sister facility and admission paperwork by POC due date of 12/10/2024.

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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:Lizzette Tellez
LICENSING EVALUATOR NAME:Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
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