306006030-9-22-2021-22-AS-JTIE-C74R55-20210922124233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006030
Report Date: 09/22/2021
Date Signed: 09/22/2021 12:42:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MAJESTIC CARE VILLA INC.		FACILITY NUMBER:	306006030
ADMINISTRATOR:	FAJARDO, MIGUELITO		FACILITY TYPE:	740
ADDRESS:	25531 ALTHEA AVE		TELEPHONE:	(949) 290-3917
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/22/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Administrator, Miguelito Fajardo		TIME COMPLETED:	12:55 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) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a single story residential home. LPA along with Administrator Miguelito "Bing" Fajardo toured facility. Fire clearance approval was received on 07/06/21. Structure: Facility is a one story, 6 bedroom (5 Residents bedrooms and 1 live in staff bedroom) 2 bathroom house with no garage and a gray exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Facility has 2 extinguishers. Facility has audible alarms on all sliding/exit doors. Appliances: Electric Stove and refrigerator are operational. Toxins: LPA observed toxins secured in laundry storage area.. Water Temperature: Tested and recorded at 114.9 degrees F. in facility bathrooms. Reading Material Games, and Equipment: facility does exercises, puzzles and trivia card games. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on both sides of facility as required. LPA observed shaded outdoor seating. CONTINUED ON LIC 809C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAJESTIC CARE VILLA INC.	FACILITY NUMBER: 306006030
	VISIT DATE: 09/22/2021

NARRATIVE

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Administrator's Certificate observed on wall expiring March 9,2023.

Component III Orientation was waived during this pre-licensing visit due to Administrator presently operating several facilities.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.

An exit interview was conducted with Administrator and a copy of report was left at facility

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

LIC809 (FAS) - (06/04)

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