Avocado Creek

Allegation investigated: Staff did not ensure that a resident was provided with a safe environment

On 01/14/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to investigate the allegation listed above. LPA met with Administrator Marija Banovic who was informed of the purpose of the visit. LPA toured the facility, conducted interviews, and obtained copies of pertinent documentation. Regarding the allegation, “Staff did not ensure that resident was provided a safe environment” it was alleged on 01/02/2026 and 01/04/2026, Resident 1 (R1) reported wanting to get a gun to kill Resident 2 (R2). It was further alleged on 01/03/2026, R1 slapped R2 in the facility. During the tour, LPA did not observe any firearms in the home. LPA reviewed an Unusual Incident/Injury Report (LIC 624) dated 01/03/2026 documenting on 01/02/2026 at 1:20 p.m. Staff 1 (S1) and a nurse observed R1 stand up from a reclining chair in the living room, begin walking towards R2, and slapped R2 for no reason. The LIC 624 documents police were called and R1 was transported to the hospital by police on 01/04/2026. Unsubstantiated S1 was interviewed and reported the following information. The incident occurred on 01/02/2026 not 01/03/2026 as alleged and was an isolated incident involving R2. On 01/02/2026, S1 was speaking with a hospice nurse in the kitchen when they observed the incident as described in the LIC 624. S1 and the nurse immediately responded to the scene, separated and redirected the residents, assessed R2 for injuries/pain, and called law enforcement and Administrator Banovic. R1 claimed to have a gun and threatened to kill R2. However, R1 does not own a gun, nor did they have the means to go out to purchase one. R1 has resided in the facility since October 2025 and prior to this incident, R1 had not exhibited any signs of aggression in the past. Law enforcement and administrator responded to the facility, and law enforcement determined that due to R1’s cognitive impairment and limited physical capabilities, R1 was not realistically able to gain access to a firearm to carry out the threat. Law enforcement advised S1 to follow up with the Crisis Response Team (CRT) and request an evaluation for R1. Law enforcement determined it was safe for R1 remain in the facility pending CRTs evaluation. As a result, S1 was assigned by administrator to provide 1:1 care and supervision to R1 to ensure the safety of R2 and the remaining residents pending the CRTs evaluation results. A witness interview was conducted with the hospice nurse identified from the LIC 624. This witness corroborated the information provided by S1 and added they also assessed R2 for injuries. The witness reported they have visited R2 in the facility twice a week since 02/01/2025 and have never witnessed R1 or any other resident make verbal threats or display physical aggression towards R1 or other residents. Administrator was interviewed, corroborated the information provided by S1 and added the following information. There are no firearms stored in the facility. On 01/03/2026, S1 contacted CRT due to R1 aggressing towards staff. Law enforcement responded to the facility and determined it was safe for R1 to remain in the facility pending their CRT evaluation scheduled for 01/04/2026. On 01/04/2026, R1 was hospitalized as a result of the CRT evaluation. Administrator reported they ensured the safety of all residents in care and even offered R1 a private room to avoid further possible incidents by residing with a roommate, to which R1 accepted. Administrator maintained contact with R1’s responsible person who was in the process of arranging for R1 to also be evaluated by their primary care physician. LPA conducted an interview with R1’s responsible person who reported facility staff have done a fantastic job despite current difficult circumstances. R1’s responsible person reported prior to this incident, R1 did not display any aggression. They reported R1 does not own a firearm, has never touched one, and is not able to gain access to one. LPA reviewed R1’s signed physician’s report dated 10/23/2025 documenting R1 has dementia. The “Expressions of Frustration” subsection in R1’s physician’s report is marked “No”. This subsection is nested under the category “Behavioral Expressions” defined as behavior(s) displayed by a resident that may result in harm to self or others. LPA reviewed a letter from the Department of Justice dated 01/05/2026 addressed to R1 prohibiting them from possessing or gaining access to a firearm or any other deadly weapon beginning 01/04/2026 to 01/04/2031. R1 refused to be interviewed. LPA conducted an interview with R2 who recalled the incident as described in the LIC 624 and reported S1 ran to the incident location to intervene and assess them for injuries. R2 reported they did not experience any verbal threats or physical aggression from R1 or any other residents in the home prior to this incident. R2 reported S1 offered them immediate medical attention to which R2 declined. LPA made contact with the reporting party who reported facility staff intervened and responded appropriately to the incidents involving R1 and R2. LPA was unable to identify any additional possible witnesses. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Banovic.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 18-AS-20260106095207

Allegation investigated: Night staff do not respond to resident's call for assistance Staff left resident in soiled diapers for an extended time period Staff on duty is unable to transfer resident

On 12/16/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced visit to deliver findings regarding the allegations listed above. LPA met with Licensee, Marija Banovic who was informed of the purpose of the visit. It was alleged Resident 1 (R1) uses a bell to call for assistance during night hours, but facility staff cannot hear it and do not respond. It was further alleged R1 does not receive incontinent care throughout the night and facility staff are unable to transfer R1 when using the hoyer lift. R1 was interviewed and corroborated the allegations. Regarding the allegation "Night staff do not respond to resident's call for assistance", LPA reviewed the facility’s program description noting each resident will receive routine observation, care, and supervision. LPA reviewed R1’s Physician’s Report (LIC 602A) dated 3/21/23 indicating R1 is able to communicate their needs and does not exhibit confusion or wandering behavior. LPA also reviewed R1’s Appraisal/Needs and Services Plan (LIC625) dated 2/15/2023 noting R1 exhibits confusion. Licensee was interviewed and reported overnight staff have a baby monitor near them to listen and respond to resident bell calls, incidents, and emergencies. Unsubstantiated Two (2) care staff were interviewed and reported they check on the residents three (3) times during night hours and are able to hear resident bell calls from the baby monitor. Both staff interviewed reported they have not received complaints from residents reporting they sounded the bell during night hours and did not receive assistance. Two (2) additional residents were interviewed of which one (1) reported they are independent and do not require assistance from facility staff. One (1) of two (2) residents interviewed reported they do not require assistance from staff during night hours and only sound the bell to call for help during the day, to which facility staff respond in a timely manner. Regarding the allegation "Staff left resident in soiled diapers for an extended time period" R1's LIC 602A indicates R1 does not have the capacity to care for their own toileting needs. Staff 1 was interviewed and reported R1 exhibited memory lapses as evidenced by their complaints of staff not providing incontinent care moments after S1 changed their brief. An additional staff was interviewed and reported they assist R1 with incontinent care as necessary. Two (2) residents were interviewed, of which one (1) reported they do not require assistance with incontinent care. One (1) of two (2) residents interviewed reported facility staff provide incontinent care to them in a timely manner. Regarding the allegation "Staff on duty is unable to transfer resident" R1's LIC 602A indicates R1 is non-ambulatory and does not have the capacity to independently transfer themselves to and from bed. Licensee reported all facility staff received hoyer lift training to assist R1 with transfers. LPA reviewed the facility’s Training Log signed by facility staff documenting on 9/6/2023 they received a one (1) hour hoyer lift operation training for R1. Two (2) staff were interviewed and confirmed they received hoyer lift training and added they assist R1 with transfers anytime they request it. Two (2) residents were interviewed, of which one (1) reported they are able to independently transfer themselves to and from bed. One (1) of two (2) residents interviewed reported staff assist them with transfers each time they request it. Information gathered by the two (2) additional residents interviewed did not corroborate or refute the allegations. LPA made several attempts to contact R1's responsible person for an interview but was unsuccessful. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 18-AS-20230901085939

Type of visit: Required - 1 Year

n 11/14/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Marisa Hipolito who was informed of the purpose of the visit. Licensee, Marija Banovic arrived during the visit. The facility has a fire clearance for 12 non-ambulatory elderly residents of which one (1) may be bedridden. The facility also has an approved hospice waiver for five (5) and LPA was informed three (3) residents are currently receiving hospice services at the facility. During the visit, there was eight (8) residents and two (2) staff present. LPA toured the facility with Caregiver Hipolito and observed the facility is made up of a one-story home with 10 resident bedrooms, seven bathrooms, a kitchen, dining room, and attached garage. Resident bedrooms had the required bedding, furniture and lighting. Bathrooms had grab bars and non-skid mats in the showers. Indoor and outdoor passageways were free of obstruction. The facility had a two-day supply of perishable foods and seven-day supply of non-perishable foods, which were stored in a safe and healthful manner. Knives are secured in a locked kitchen drawer. Medications are secured in a locked dining room cabinet. LPA toured the garage and observed an operating laundry washer and dryer along with additional incontinent supplies, blankets, comforters, food and water. Cleaning solutions are secured in a locked storage cabinet in the garage. Licensee Banovic tested one of the smoke alarms/carbon monoxide detectors and LPA observed it to be operation. LPA also observed charged fire extinguishers mounted throughout the facility, last serviced on 6/26/2024. Staff present have a criminal record clearance and valid first aid/cardiopulmonary certification. LPA reviewed the facility's Fire Drill Log noting the facility's last fire drill was conducted on 10/13/2024. Complaint information, facility sketch, and emergency phone numbers are visibly posted near the front entrance and dining room walls. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee Banovic.the state’s words, verbatim · CDSS document, Nov 14, 2024

Type of visit: Required - 1 Year

On November 29, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection, and met with the Administrator, Marija Banovic. LPA Mixson toured the facility, along with the Administrator, Marija Banovic, and inspected the inside and outside of the facility. There were no obstructions to indoor and/or outdoor passageways at the time of this visit. The facility is a single story home, located at 1080 Avocado Ave Escondido CA 92026. Physical Plant: The facility is not operating in the capacity approved by Community Care Licensing (CCL), which is 12, but has 9 residents at the time of this visit. The facility phone number is (760)822-5860, and is operable at this time. The LPA observed the resident's bedrooms, and each was equipped with required furniture; including bed & mattresses, night stands, storage space, and sufficient lighting. The LPA inspected the residents bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and a fire extinguisher. Posters such as; the Ombudsman and CCL complaint poster were posted in a common area. The cleaning supplies, toxins, and sharps were kept inaccessible to residents in care. There was a designated storage space for resident and staff files. Medications: were reviewed, and were locked and inaccessible to the residents. The overall facility is clean, in good repair, and operating in safe conditions for residents currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient for number of residents, and there are a variety of food types available for the residents. Dishes and utensils were also stored properly. Care & Supervision: Facility has sufficient staff, and staff were engaging the residents during this visit. Record Review: LPA Mixson interviewed two staff, the residents were not available at the time of this visit. The LPA reviewed four resident files, and two staff files, and the required CCL reports from previous visits. There were no observable Title 22, Division 6 Regulation violations observed and/or cited during todays visit. An exit interview was conducted and a copy of this report was given to the Administrator, Marija Bancovic.the state’s words, verbatim · CDSS document, Nov 29, 2023