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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604308
Report Date: 08/27/2025
Date Signed: 08/27/2025 01:55:35 PM

Document Has Been Signed on 08/27/2025 01:55 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:CARLOVY HOMES IN CARLSBADFACILITY NUMBER:
374604308
ADMINISTRATOR/
DIRECTOR:		RADOVANIC, ANAFACILITY TYPE:
740
ADDRESS:1275 CYNTHIA LANETELEPHONE:
(623) 341-2794
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 6CENSUS: 5DATE:
08/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Head Caregiver Emmanuel RodriguezTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hannah Rodgers and Janet Ngallo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit.  LPAs were welcomed by and discussed the purpose of the visit to Head Caregiver Manny Rodriguez. The facility's license shows a maximum capacity of six (6) residents, three (3) of whom may be ambulatory, and three (3) of whom may be non-ambulatory. During today’s inspection there were five (5) residents in care.

LPAs and Head Caregiver Manny Rodriguez toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Residents bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. LPAs observed five (5) unlabeled daily medication containers that were filled with residents medications poured in advance in a locked cabinet located in the kitchen. The medications in the daily containers were not in its originally received container and had been transferred from their originally received container. No pools or bodies of water exist on the premises. Per Head Caregiver Manny Rodriguez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

[CONTINUED ON LIC809-C]
 
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Hannah Rodgers
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/27/2025 01:55 PM - It Cannot Be Edited


Created By: Hannah Rodgers On 08/27/2025 at 01:14 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: CARLOVY HOMES IN CARLSBAD
FACILITY NUMBER: 374604308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that five (5) out of five (5) resident's medications were transferred to a different a container for days in advance, which poses a potential health and safety risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Licensee agreed to conduct an in-service training on centrally stored medications and provide the Department proof of this training with a sign-in sheet and training agenda by POC date of 09/24/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Hannah Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CARLOVY HOMES IN CARLSBAD
FACILITY NUMBER: 374604308
VISIT DATE: 08/27/2025
NARRATIVE
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LPAs reviewed facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas.
 
One deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A plan of correction was jointly formulated, and an exit interview was conducted with Head Caregiver Rodriguez, to whom a copy of this report, LIC809-C, LIC809-D and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Hannah Rodgers
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
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