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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403554
Report Date: 04/19/2024
Date Signed: 04/19/2024 03:07:11 PM

Document Has Been Signed on 04/19/2024 03:07 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAJINTIN VILLEFACILITY NUMBER:
336403554
ADMINISTRATOR/
DIRECTOR:		VERLY S. FRIASFACILITY TYPE:
740
ADDRESS:69275 EL CANTO ROADTELEPHONE:
(760) 202-2763
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 3DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Verly Frias - Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Verly Frias and informed him of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap and paper towels at hand washing stations and tight-fitting lids on trash cans.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 109.5 degrees. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed multiple chemicals in the cabinet under the sink, which was unlocked. Deficiency cited. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. Knives are kept locked up and away from resident reach.

Operational Requirements: The facility has a licensed capacity of 6 non-ambulatory residents. Facility has a hospice waiver for 2 residents. LPA Colvin observed that Resident One (R1) is bedridden, and the facility does not have bedridden fire clearance. Deficiency cited. Violations of a facility's fire clearance result in an immediate civil penalty of $500, which LPA Colvin will be assessing today. LPA Colvin additionally notes that she cited the facility for the same violation on 8/27/21 during a Case Management Visit. Part of the Plan of Correction was that the Licensee/Administrator submitted a Statement of Understanding that they are not permitted to accept or retain bedridden residents without proper fire clearance.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAJINTIN VILLE
FACILITY NUMBER: 336403554
VISIT DATE: 04/19/2024
NARRATIVE
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Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator present at the facility. LPA Colvin observed that the Administrator's Administrator Certificate expired 4/10/24. LPA Colvin was not able to verify the submission of a renewal with the Administrator Certification Branch, but the Licensee/Administrator was able to provide LPA Colvin with a Certified Mail Return Receipt dated 2/13/24 and addressed to the Administrator Certification Branch. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs.

Resident Records: LPA Colvin reviewed the files for all 3 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that 2 of 3 residents (R2 & R3) do not have a completed Needs & Services Plan in their file. Deficiency cited. LPA Colvin observed that R2 does not have a Pre-Admission Appraisal in their file. Deficiency cited. LPA Colvin observed that R3's Admissions Agreement is missing most of the important information, such as facility information, rate for services, and services provided. Deficiency cited.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions.



Planned Activities: LPA Colvin confirmed that the facility provides activities for residents to engage in.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file, but is not conducting quarterly emergency disaster drills, which are to be done quarterly. Deficiency cited.

Other: LPA Colvin observed that the facility has outstanding unpaid licensing fees in the amount of $989. Deficiency cited

An exit interview was conducted with Administrator/Licensee Verly Frias and a copy of this report, LIC809D, LIC421IM, and appeal rights were provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/19/2024 03:07 PM - It Cannot Be Edited


Created By: Crystal Colvin On 04/19/2024 at 02:28 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: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. 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 approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 3 residents, which poses an immediate health and safety risk to persons in care. LPA Colvin observed that R1 is bedridden, according to their Physician's Report. Physician's Report additionally indicates that it is a permanent condition.
POC Due Date: 04/20/2024
Plan of Correction
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Licensee agrees to immedaitely notify the local Fire Department of the presence of a bedridden resident. Licensee additionally states that they will have the resident's physician either submit a statement that R1 is not bedridden, or they will redo the Physician's Report to reflect this. Copy to be submitted to LPA Colvin by Plan of Correction date of 4/20/24.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 area of the facility (cabinet under kitchen sink), which poses an immediate health and safety risk to persons in care. LPA Colvin observed numerous cleaning chemicals in the cabinet under the kitchen sink, which was unlocked and accessible.
POC Due Date: 04/20/2024
Plan of Correction
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Licensee agrees to immediately secure chemicals and to conduct walk-through of the facility to ensure no other unlocked chemicals. Licensee may self-certify once complete.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/19/2024 03:07 PM - It Cannot Be Edited


Created By: Crystal Colvin On 04/19/2024 at 02:28 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: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onrecord review, the licensee did not comply with the section cited above in 1 of 3 residents, which posed a potential health, safety or personal rights risk to persons in care. LPA Colvin observed that R2 did not have a completed Pre-Admission Appraisal in their file.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee agrees to complete a Pre-Admission Appraisal for R2 and provide a copy to LPA Colvin by the Plan of Correction date of 5/3/24.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in4 of 4 quarterly disaster drills, which poses a potentia safety risk to persons in care. LPA Colvin confirmed with Licensee/Administrator that there are no documented Emergency Disaster Drills for the facility.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee agrees to complete a Disaster Drill with staff and residents and maintain a record of the drill in a file at the facility. Licensee will create a tentative schedule for quarterly diaster drills. Proof of disaster drill and tentative schedule for future drills to be provided to LPA Colvin by Plan of Correction date of 5/3/24.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/19/2024 03:07 PM - It Cannot Be Edited


Created By: Crystal Colvin On 04/19/2024 at 02:30 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: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(a)
Admission Agreements: (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 3 residents, which poses a potential personal rights risk to persons in care. LPA Colvin observed that R3's Admissions Agreement is primarily blank, with important information (such as facility information, rate for charges, and services provided) left blank
POC Due Date: 05/03/2024
Plan of Correction
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Licensee agrees to complete a new Admissions Agreement with R3/R3's family to ensure that they are aware and agreeing to the complete information needed to be present in the agreement. Licensee to provide a copy of the new Admissions Agreement to LPA Colvin by Plan of Correction date of 5/3/24.
Type B
Section Cited
CCR
87506(a)
Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in2 of 3 residents, which poses a potential personal rights risk to persons in care. LPA Colvin observed that R2 & R3 do not have a completed Needs & Services Plan in their file.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee agrees to complete a Needs & Services Plan for R2 & R3 and provide a copy to LPA Colvin by Plan of Correction date of 5/3/24.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/19/2024 03:07 PM - It Cannot Be Edited


Created By: Crystal Colvin On 04/19/2024 at 02:43 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: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87156(a)
Licensing Fees: (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above with outstanding Licensing Fees due to the Department, which poses a potential health, safety or personal rights risk to persons in care. LPA Colvin observed that the facility has outstanding Licensing Fees in the amount of $989.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee agrees to pay the outstanding Licensing fees. Licensee may self-certify to LPA Colvin once complete. Due by Plan of Correction date of 5/3/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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