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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604082
Report Date: 11/15/2021
Date Signed: 11/15/2021 05:21:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MAJESTIC VILLA ASSISTED LIVINGFACILITY NUMBER:
374604082
ADMINISTRATOR:KAHNIS, QUETZALLIFACILITY TYPE:
740
ADDRESS:1910 WOODSIDE DRTELEPHONE:
(442) 231-8517
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY:6CENSUS: 6DATE:
11/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Siklalic Garcia, Facility ManagerTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit at the facility, to complete a health and safety check for clients in care. LPA identified herself and was granted entry by Aurora Lopez, Caregiver. LPA met with Siklatic Garcia, Facility Manager and disclosed the purpose of the visit.

The facility self-reported an incident regarding Resident 1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing on November 5, 2021. During today's visit, LPA toured the facility, spoke with staff, residents and Licensee, and reviewed and obtained resident records maintained by the facility. No immediate health or safety concerns were observed. No deficiencies were cited during today’s visit.

An exit interview was conducted with Facility Manager Garcia, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), was provided to the Quezalli Khanis Licensee and Facility Manager Garcia via electronic mail. An electronic read receipt confirms the documents were received.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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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