306006030-9-13-2024-22-AS-KSGH-D93VK7-20240913162951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006030
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:30:38 PM

Document Has Been Signed on 09/13/2024 04:30 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
ORANGE COUNTY RO, 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:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Miguelito Fajardo, Administrator		TIME COMPLETED:	04:35 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 this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by the facility's caregiving staff after introducing himself and stating the reason of the visit. Administrator Miguelito Fajardo was notified via telephone and arrived later to assist with the visit. During the inspection, LPA and staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with three private and one shared bedrooms in addition to the facility's common living areas. There is an additional room for use by live-in staff. There is one shared bathroom and one bathroom located en-suite with the shared bedroom. Both are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linen and blankets. One bed is observed to be equipped with half rails and another one with full rails for postural support. Physician orders and hospice plan of care and admission reviewed for both residents. There are currently four residents admitted to the facility, two of which are receiving hospice care. One of these residents is assessed to be bedridden in their most recent physician report and the previous one. The facility's fire clearance does however not include any provision for bedridden residents. A type A citation is therefore issued on an attached LIC809-D for this deficiency. Bathrooms faucets and toilets are operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers are listed and available for review by staff in a folder. Drills are conducted quarterly and documented. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present are fully charged with up-to-date maintenance tags. There is adequately shaded outside space with outdoor furniture present. There is a self-latching gate on one side. The route of egress is free of obstructions. There are no bodies of water on the premises. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MAJESTIC CARE VILLA INC.	FACILITY NUMBER: 306006030
	VISIT DATE: 09/13/2024

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 FORM LIC809
Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders.

LPA reviewed four resident files and three staff files. Resident records include all necessary components. All staff members are confirmed to be cleared and associated with this particular licensed location. Training records and CPR training on file and up-to-date.

Based on the observations made during today’s inspection, one type A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/13/2024 04:30 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
ORANGE COUNTY RO, 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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records reviewed, the licensee did not comply with the section cited above as one resident is observed in bed and assessed by their primary care provider to be bedridden without an applicable fire clearance in place. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/14/2024
	Plan of Correction
1 2 3 4	Licensee will provide a statement indicating their intent to obtain an updated fire clearance and submit an updated licensing formSTD 850 to the Department to request a visit from the Fire Marshall as soon as possible.

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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3