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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403554
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:00:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
05/12/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230512163605
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:
05/17/2023
UNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Carmelita McNeff, CaregiverTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff failed to administer resident's medications as prescribed
Staff are not ensuring resident's hygiene needs are met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to initiate a complaint investigation for the allegations listed above. LPA Gardner met with Caregivers Carmelita McNeff, and Emenita Pacia and then toured the facility. Administrator Verly Frias arrived while LPA was inside the facility. LPA informed staff of the purpose of the visit and the elements of the allegation. LPA conducted a record review of Resident One (R1)'s file, interviewed R1 (via telephone), and interviewed staff.

It was alleged that staff do not pick up medications for R1 and do not provide the medications to them.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
05/12/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230512163605

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:
05/17/2023
UNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Carmelita McNeff, CaregiverTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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2
3
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9
Staff do not assist resident with meeting medical needs
Staff do not ensure resident is fed
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to initiate a complaint investigation for the allegations listed above. LPA Gardner met with Caregivers Carmelita McNeff, and Emenita Pacia and then toured the facility. Administrator Verly Frias arrived while LPA was inside the facility. LPA informed staff of the purpose of the visit and the elements of the allegation. LPA conducted a record review of Resident One (R1)'s file, interviewed R1 (via telephone), and interviewed staff.


Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20230512163605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAJINTIN VILLE
FACILITY NUMBER: 336403554
VISIT DATE: 05/17/2023
NARRATIVE
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It was then alleged that R1 was not being taken to his follow up appointments, and further, staff were not assisting R1 with meeting their medical needs. LPA reviewed documents provided by the facility and found that R1 was admitted to the hospital for contracting COVID-19 on May 9, 2023, and prescribed medication to handle the diagnosis. R1 continued to receive medical care for an undiagnosed condition. Prior to that, the facility provided the most recent After Visit Summary dated March 3, 2023 which noted no additional follow-up visit was scheduled; therefore, there was no additional follow-up for the facility to provide. Thus, the allegation was Unsubstantiated.

It was then alleged that the facility was not feeding R1. Interview with R1 and staff indicated that R1 was fed, and there was no concern with R1 not having enough food. Thus this allegation was Unsubstantiated, as a result.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where a copy of this report was discussed and provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20230512163605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAJINTIN VILLE
FACILITY NUMBER: 336403554
VISIT DATE: 05/17/2023
NARRATIVE
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 Interview with staff revealed that medications are picked up for R1 by their friend, and delivered to the facility. LPA inspected the Medication Administration Record (MAR), and; although complete, when questioned, staff advised that R1 was not getting their medication as prescribed. Thus this allegation was Substantiated.

It was then alleged that staff do not assist R1 with hygiene and do not help them bathe. Interview with staff indicated that R1 was difficult to bathe, and would often refuse. Staff interview revealed that R1 should be afforded baths, but due to R1's refusal and behavior, none are offered. R1 is; however, afforded a bed bath once in awhile. Thus, this allegation was Substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Thus the facility was cited per Title 22.

An exit interview was conducted where a copy of this report was discusses and provided along with copies of the LIC9099D, and Appeal Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20230512163605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MAJINTIN VILLE
FACILITY NUMBER: 336403554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2023
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care: (a) A plan for incidental medical..shall be developed by each facility. The plan shall encourage routine medical ..provide for assistance in obtaining such care..(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not being met as evidenced by:
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Licensee to develop a plan to provide R1 with their medications, as well as conduct in-service training for staff on the cited regulation. Proof of such is to be provided to LPA by POC date.
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Based on interview, LPA discovered that staff were not assisting with R1 with receiving their medications nor in administrating them. This is a potential health and safety risk to residents in care.
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Type B
05/24/2023
Section Cited
CCR
87468.2(a)(8)
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Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition ..for the elderly shall have all of the following personal rights:(8) To be free from neglect, .. or sexual abuse. This requirement was not being met as evidenced by:
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Licensee agrees to conduct in-service training on the cited regulation (Personal Rights) and provide proof of training to LPA by POC date.
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Based on staff interview, LPA found that R1 was not being afforded baths by staff. This is a potential personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5