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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 04:57:08 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Siklatic Garcia, Facility ManagerTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Aurora Lopez, Caregiver. LPA met with Facility Manager Siklatic Garcia, Facility Manager and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA, accompanied by Facility Manager conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Facility Manager. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Facility Manager Garcia and Licensee at the conclusion of the visit. LPA requested Facility Manager or for the Licensee Quetzalli Kahnis to send LPA an electronic message reply confirming receipt of these documents.

A current Personnel Report LIC 500, Designation of Administrative Responsibility LIC 308 and an Emergency Disaster Plan LIC 610-E was given to LPA during the visit. Form are also available at www.ccld.ca.gov.
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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