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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403554
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:11:25 PM

Document Has Been Signed on 08/31/2021 03:11 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: DATE:
08/31/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Verly S. Frias - Licensee/AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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An Informal Meeting was conducted today via Zoom due to COVID-19 in order to discuss recent concerns and facility's operation. Persons present at today’s meeting were: Licensing Program Manager (LPM) Joel Esquivel, Licensing Program Analyst (LPA) Crystal Colvin, and Licensee/Administrator Verly S. Frias.
Below are the topics that were addressed during the Informal Meeting tele-visit:
  • Reporting Requirements

  • Training Records for Staff

  • Bedridden Clearance

  • Facility's Options Regarding Resident Currently Awaiting Hospital Discharge

  • Retaliation for Complaints
  • History of Facilities (Cathedral Manor & Majintin Ville)



LPA Colvin will additionally be issuing the facility a deficiency for the facility's consistent failure to report events concerning residents' health and well-being to Community Care Licensing. Additionally, LPA Colvin will be citing a deficiency for false statements due to the Licensee having possession of blank signed training certificates, which matches those of staff on file (observed by LPA Colvin on 8/27/21 visit).

LPM Joel Esquivel and LPA Crystal Colvin offered Licensee Verly S. Frias the Technical Support Program (TSP) Assistance. The Licensee declined the TSP Program at this time.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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: 08/31/2021
NARRATIVE
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An exit interview was conducted and a copy of this report along with LIC809D with deficiencies noted, and appeal rights were provided via email to Licensee/Administrator Verly S. Frias for signature.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2021 03:11 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/31/2021 at 02:55 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: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2021
Section Cited
CCR
87207

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False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met by:
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Licensee agrees to discard the certificates in question and ensure that all training documents for staff are legitimate and verifiable. No further Plan of Correction required.
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Based on observations and record review, the Licensee did not comply with the above regulation with staff training certificates. LPA Colvin observed the facility to be in possession of blank signed training records. This is an immediate safety risk to residents.
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Type B
09/07/2021
Section Cited
CCR87211(a)(1)

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Reporting Requirements: (a) Each licensee shall furnish...such reports... including,...:(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events... This requirement was not met by:
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Licensee to submit to LPA Colvin any incident reports from August 2020 to current date, to ensure that they are reviewed and logged. Licensee agrees to submit reports for all reportable incidents (according to Title 22 Regulations) to Licensing in timely manner.
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Based on record review, the Licensee did not comply with the above regulation. LPA Colvin observed that no incident reports have been submitted to Licensing since July 2020. This is a potential safety risk for all residents in care.
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Plan of Correction date is 9/7/21.
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: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021


LIC809 (FAS) - (06/04)
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