374603683-8-9-2026-18-AS-CTUA-DXH6H9-20260831204905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603683
Report Date: 02/23/2023
Date Signed: 08/09/2026 02:24:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2023 and conducted by Evaluator Janira Arreola

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230217085412

FACILITY NAME:	BREEZE HILL CARE		FACILITY NUMBER:	374603683
ADMINISTRATOR:	SMILJA MILOSAVLJEVIC		FACILITY TYPE:	740
ADDRESS:	799 MARSOPA DRIVE		TELEPHONE:	(760) 631-0267
CITY:	VISTA	STATE: CA	ZIP CODE:	92081
CAPACITY:	6	CENSUS: 6	DATE:	02/23/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Smilja Milosavljevic		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility failed to safeguard a resident's personal belongings

INVESTIGATION FINDINGS:

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The following report has been amended: Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct an investigation into the allegation above. LPA met with the Administrator, Smilja Milosavljevic, who was informed of the purpose of the visit.LPA conducted interviews, documented observations and collected documentation for the resident. Regarding allega

tion " Staff did not complete an initial personal property inventory when resident entered the facility. " It was alleged that the facility staff failed to complete a personal property inventory form for the resident. The LPA reviewed the resident's file and found that the facility did complete this form and obtained a copy of this. When facility staff was interviewed on what belongings the resident came to the facility with, the staff responses were consistent with the personal property form that was filled out.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230217085412

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BREEZE HILL CARE	FACILITY NUMBER: 374603683
	VISIT DATE: 02/23/2023

NARRATIVE

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The following report has been amended: Regarding allegation, "Facility failed to safeguard a resident's personal belongings". It was alleged that Resident #1 (R1)'s dentures were misplaced at the facility. LPA conducted interviews, reviewed records, and documented observations. LPA conducted a file review and found in R1's file that the dentures were received by the facility, with the form stating that the bottom and top dentures were received. The facility staff was interview who stated that they were not sure if the dentures received were the top and the bottom dentures. Staff also consistently reported in interviews that the dentures did not fit R1. Staff interviews also corroborated that the administrator was informed of the dentures not fitting the resident and R1's responsible party being informed of this. They also stated that R1 did not wear their dentures while at the facility, due to them not fitting. Staff stated that the dentures where kept in a plastic case while at the facility in the resident's private bathroom. Staff also consistently reported that R1 did not wear dentures due to a special diet, which enabled R1 to eat without dentures. LPA observed the room (Room #1) that was R1's bedroom. LPA observed this is a private room with a private restroom. LPA interviewed staff who stated that no other residents used dentures at the facility. R1 is no longer residing in the facility as was discharged on. 01/08/2023.

Therefore, based on observation, interview and records review, it was found that the allegations are unsubstantiated. A finding of unsubstantiated means that although the allegation is valid, the preponderance of the evidence standard has not been met.

An exit interview was conducted with Administrator, Smilja Milosavljevic, where this report was reviewed and provided to them.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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