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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603346
Report Date: 08/09/2024
Date Signed: 08/14/2024 06:37:48 PM

Document Has Been Signed on 08/14/2024 06:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VILLA ADRIANAFACILITY NUMBER:
374603346
ADMINISTRATOR/
DIRECTOR:
ADRIANA DRAGOVICFACILITY TYPE:
740
ADDRESS:1678 SUNSET DRIVETELEPHONE:
(760) 941-0787
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY: 6CENSUS: 6DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:53 AM
MET WITH:ADMINISTRATOR, ADRIAN DRAGOVICTIME VISIT/
INSPECTION COMPLETED:
01:48 PM
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On August 09, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Adriana Dragovic. The facility file review was conducted in the Regional Office and additional forms were reviewed and requested on site. The facility is licensed for six Elderly Adults and is currently operating at a capacity six.

LPA Mixson toured the facility along with Administrator, and inspected the facility inside and outside, and there were no obstructions or debris to the indoor or outdor passageways at the time of this visit. The facility is a single-story home located at 1678 Sunset Dr. Vista CA 92081.

Physical Plant: Facility phone number is (760) 941-0787 and it is operable. The LPA observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" the "Personal Rights." The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit, and there were safety lights for night throughout the facility.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked.

Care & Supervision: Facility has sufficient staff, three staff on site at the time of this visit, and six residents after the noon meal and are napping.

Records Review: LPA reviewed resident and staff files, and conducted staff interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was discussed and given to Administrator, Adriana Dragovic.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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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