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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403554
Report Date: 08/27/2021
Date Signed: 08/27/2021 03:15:46 PM

Document Has Been Signed on 08/27/2021 03:15 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:MAJINTIN VILLEFACILITY NUMBER:
336403554
ADMINISTRATOR:VERLY S. FRIASFACILITY TYPE:
740
ADDRESS:69275 EL CANTO ROADTELEPHONE:
(760) 202-2763
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 2DATE:
08/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Verly Frias - Administrator/LicenseeTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to investigate a complaint (#18-AS-20210825090919). During LPA Colvin's review of records at the facility, LPA Colvin observed some additional deficiencies. LPA Colvin met with Administrator/Licensee Verly Frias and advised Verly of the purpose of the visit. Below are the issues that were discussed:
  • Current Staff Training - LPA Colvin reviewed facility files and observed that prior resident (R1) was bedridden and had a G-Tube (gastronomy tube). LPA Colvin reviewed staff files and observed that facility staff (S1 & S2) were not trained in care of bedridden residents or in providing care for G-Tubes. Deficiencies cited.

  • Care of Bedridden Residents - LPA Colvin observed that the facility does not have fire clearance for bedridden residents, yet R1 was admitted and retained at the facility while bedridden for almost 1 year. Licensee informed LPA Colvin that R1 was on Hospice, which permits them to retain R1. LPA Colvin informed Licensee that Title 22 Regulation 87633(l) states that while the facility may retain a bedridden person on Hospice, they must still meet all the requirements of regulation section 87606. The facility has not met the requirements of 87606 as observed in this report. Deficiency cited. A violation of a facility's fire clearance results in an immediate $500 civil penalty, which will be issued at the end of the exit interview. Additionally, the facility does not have a Plan of Operation on file which includes care of bedridden residents. Deficiency cited.

  • Hospice Records - LPA Colvin observed that the facility did not have any documentation relating to the Hospice care of R1. S1 stated that the family removed the hospice file without their permission. LPA Colvin noted that there should be a copy of the Care Plan in R1's file, which there was not. Deficiency cited.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: MAJINTIN VILLE
FACILITY NUMBER: 336403554
VISIT DATE: 08/27/2021
NARRATIVE
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  • Unscrupulous Training Certificates - During LPA Colvin's review of staff files, LPA Colvin observed that the CPR certifications for all staff were expired. LPA Colvin inquired about current certification for staff, which S1 was able to provide to LPA Colvin after bringing out a separate large envelope. At this time, LPA Colvin observed several stacks of training certificates which looked identical from those found in staff files, though these certificates were blank where the staff name would be listed. LPA Colvin looked through these certificates and observed that they were identical to those in staff files, right down to listing all of the same training, same date, and same instructor. LPA Colvin questioned Administrator/Licensee Verly Frias regarding the certificates, and showed him the ones in staff files.

    • Administrator/Licensee Verly Frias denied knowledge of these and could not account for who's signature the trainer on the certificates was, nor did he have their contact information. LPA Colvin reminded Verly that he is both the Licensee and Administrator for the facility, so he should have knowledge regarding staff training records. No explanation was provided during LPA Colvin's inspection regarding these blank records.


Due to deficiencies cited today as well as concern with blank staff records, LPA Colvin invited Administrator/Licensee Verly Frias to an Informal Meeting via Zoom to discuss facility's plan for compliance. Informal Meeting will take place Tuesday, August 31, 2021 at 2:00pm.

Due to observations made by LPA Colvn, the facility was cited deficiencies and civil penalties in the amount of $500 were issued. LPA Colvin conducted an exit interview with Administrator/Licensee Verly Frias, where a copy of this report, LIC809Ds, LIC421IM, and appeal rights were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/27/2021 03:15 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/27/2021 at 02:11 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MAJINTIN VILLE
FACILITY NUMBER: 336403554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2021
Section Cited
CCR
87202(a)(2)

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Fire Clearance: (a) All facilities shall maintain a fire clearance...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance... (2) Bedridden persons. This requirement was not met as evidenced by:
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Licensee agrees to either apply for bedridden fire clearance through CCL or provide Statement of Understanding that they will not accept/retain any bedridden residents, despite Hospice status. Submission of request for clearance or Statement due by Plan of Correction date of 8/31/21.
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Based on record review, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed R1 , who is bedridden, lived at the facility for almost 1 year while the facility failed to obtain fire clearance for bedridden residents. This was an immediate safety risk for R1.
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Type B
08/31/2021
Section Cited
CCR87606(f)(1)

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Care of Bedridden Residents: (f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. This requitement was not met by:
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Licensee agrees to submit updated Plan of Operation in regards to Care of Bedridden Residents, should Licensee choose to apply for a fire clearance and request to accept these persons. If the Licensee does not wish to apply for the Fire Clearance, Licensee to submit Statement of Understanding that they
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Based on record review, the Licensee did not comply with the above regulation. The facility retained R1, who is bedridden, for almost one year without having a Plan of Operation regarding care of bedridden residents. This was a potential health and safety risk for R1.
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will not accept/retain any bedridden residents. Submission of request for clearance or Statement due by Plan of Correction date of 8/31/21.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2021 03:15 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/27/2021 at 02:22 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MAJINTIN VILLE
FACILITY NUMBER: 336403554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2021
Section Cited
CCR
87606(f)(3)

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Care of Bedridden Residents: (f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents. This requirement was not met as evidenced by:
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Licensee agrees to have all staff trained on care for bedridden residents, should Licensee plan on submitting request for bedridden fire clearance from CCL. Should Licensee choose not to file request, Licensee to provide LPA Colvin with Statement of Understanding that they will not accept/retain any bedridden.
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Based on record review, the Licensee did not comply with the above regulation with at least 2 staff members (S1 & S2). LPA Colvin observed that S1 & S2 do not have required training on care of bedridden residents, yet provided care to R1, who was bedridden. This was an immediate health risk for R1.
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Submission of staff training or Statement due by Plan of Correction date of 8/31/21.
Type A
08/31/2021
Section Cited
CCR87633(f)

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Hospice Care of Terminally Ill Residents: (f) The licensee shall maintain a record of all hospice-related training provided to the licensee or facility personnel for a period of three years. This record shall be available for review by the Department. This requirement was not met as evidenced by:
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Licensee to provide LPA Colvin with a Statement of Understanding that facility to maintain all records of hospice training for 3 years. Statement of Understanding to be provided to LPA Colvin by the Plan of Correction date of 8/31/21.
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Based on record review, the Licensee did not comply with the above regulation with at least 2 staff members (S1 & S2). LPA Colvin observed that there was no record of staff training for care of R1's G-Tube, for which R1 was receiving Hospice care for. This was an immediate health risk to R1.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/27/2021 03:15 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/27/2021 at 02:34 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MAJINTIN VILLE
FACILITY NUMBER: 336403554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited
CCR
87633(h)(4)

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Hospice Care of Terminally Ill Residents: (h) For each terminally ill resident receiving hospice services...the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plan... This requirement was not met as evidenced by:
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Licensee agrees to ensure that the facility has a copy of all care plans for all residents receiving hospice or home health services in the facility's resident record. Licensee to conduct audit of current residents and ensure this requirement is met. Licensee to self-certify to LPA Colvin once audit is complete.
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Based on record review, the Licensee did not comply with the above regulation with at least one resident (R1). LPA Colvin observed that there was no Hospice Care Plan on file for R1 in the facility's records. This is a potential health risk for R1.
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Self-certification due to LPA Colvin by Plan of Correction date of 8/31/21.

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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021


LIC809 (FAS) - (06/04)
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