306006030-8-1-2022-22-AS-KSGH-CGVR4Z-20220801124224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006030
Report Date: 08/01/2022
Date Signed: 08/01/2022 12:42:38 PM

Document Has Been Signed on 08/01/2022 12:42 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, 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: 4	DATE:	08/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Miguelito Fajardo, Administrator Robert Christian Aquino, caregiver Gaile Aquino, caregiver		TIME COMPLETED:	01:00 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	On 08/01/2022 at 11:00am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection centered on Infection Control measures. LPA arrived at facility, was greeted and granted entry by Robert Christian Aquina, caregiver after explaining the purpose of the visit. Administrator Miguelito Fajardo was also present to assist with the visit. At approximately 11:10am, LPA accompanied by Administrator toured the physical plant of the facility. LPA observed a check-in station where visitor temperatures are being documented. There are currently four (4) residents in care, one (1) of which is receiving hospice care. Residents are observed relaxing in the common areas or in their bedroom and appear clean and well taken care of. The five (5) bedrooms include all necessary components. The resident on hospice is observed to have full bed rails while another resident's bed is equipped with half rails for postural support. No written order for the support is present in the resident's file. LPA issues a Technical Advisory requiring the licensee to obtain the written order in question. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Sharp instruments are stored in a kitchen drawer, however the magnetic lock is observed to be non-functional. LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cupboard. Cleaning supplies are located in the locked laundry room. During the visit however, the door leading to the laundry room was observed to be unlocked, as was the cabinet where cleaning chemicals are stored. LPA observed the facility has COVID-19 Precautions posters and all required department postings as well as hand-washing signs in the bathrooms. Facility has an approved LIC808 Mitigation Plan on file. LPA provides consultation with licensee on the requirement to submit an updated Infection Control Plan to the Department. Facility has an adequate supply of PPE. Fire extinguishers are observed to be operational and charged. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

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: 08/01/2022

NARRATIVE

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CONTINUED FROM FORM LIC809

Staff present is adequately associated in Guardian. LPA toured the outside of the facility and observed it to be free of obstructions. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, one (1) type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2022 12:42 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

California Code of Regulations Section 87705(f)(1) states that: " The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)." This requirement is not met as evidenced by: During the visit, LPA Saborit-Guasch observed that the magnetic lock on the knife drawer is no longer operational and does not secure the content of the drawer anymore. Additionally, the laundry room is observed to be unlocked, as was the cupboard containing the cleaning supplies.
	Deficient Practice Statement
1 2 3 4	Based on observation made during today's visit, the licensee did not comply with the section cited which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2022
	Plan of Correction
1 2 3 4	Licensee will ensure the installation of an operational lock on the knife drawer and supply LPA with documentation of the installation. Licensee will also ensure the cleaning supplies and the laundry room are locked when not immediately attended by staff.

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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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