565850366-9-3-2024-29-AS-BBAI-D8RTNB-20240903145228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850366
Report Date: 09/03/2024
Date Signed: 09/03/2024 02:53:11 PM

Document Has Been Signed on 09/03/2024 02:53 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MAJESTIC RESIDENTIAL CARE		FACILITY NUMBER:	565850366
ADMINISTRATOR/ DIRECTOR:	OSILESI, KEMI		FACILITY TYPE:	740
ADDRESS:	2036 CUTLER ST		TELEPHONE:	(310) 503-2515
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 5	DATE:	09/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Kemi Osilesi		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Administrator Kemi Osilesi and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The LPA inspected the kitchen/food service area at approx. 10:05 a.m. The LPA observed resident watching television in the living room. Knives and sharp objects are stored in a locked drawer to the left of the dishwasher. Cleaning supplies were observed kept underneath the sink inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. At the time of the visit, the common area furniture's were observed to be in good condition. LPA observed multiple board games and activities stored on a book shelf in the living room. A sufficient supply of clean linen and towels were observed stored in the hallways next to Room #3. A sufficient supply of PPE and toiletries were observed stored inaccessible to residents in care in a closet next to room #1. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last purchased in August 23rd, 2024. LPA observed four (4) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAJESTIC RESIDENTIAL CARE	FACILITY NUMBER: 565850366
	VISIT DATE: 09/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 9099
At approx. 10:35am, LPA observed staff mopping floors. The staff room located to the right of the entry way was observed to be inaccessible to residents in care and empty during the time of the visit. Office was located to the right of entry way.

All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to store an additional fridge to store extra perishable food. LPA also observed laundry area, along with additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit.

Records review began at approx. 10:45am, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were observed to be in order at this time. Three (3) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.

At approx 1:30p.m, LPA observed Staff #1 (S1) to have criminal background clearance, but they were not associated to this facility.

Last emergency disaster drill was conducted on August 15, 2024.

Medications review began at approx. 1:00 p.m. All medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time.

Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAJESTIC RESIDENTIAL CARE	FACILITY NUMBER: 565850366
	VISIT DATE: 09/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 809-C

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Interviews were conducted during the visit.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $500. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/03/2024 02:53 PM - It Cannot Be Edited

Created By: Brian Balisi On 09/03/2024 at 02:24 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAJESTIC RESIDENTIAL CARE	FACILITY NUMBER: 565850366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above as S1 did not have their clearance transferred to this facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 09/04/2024. Licensee will submit proof of clearance to LPA via email by eod 09/04/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Desaree Perera

LICENSING EVALUATOR NAME:

Brian Balisi

LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4