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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604082
Report Date: 04/06/2022
Date Signed: 04/06/2022 08:11:56 PM


Document Has Been Signed on 04/06/2022 08:11 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, 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: 5DATE:
04/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Siklalic Garcia, Facility ManagerTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit to ensure ongoing compliance with laws and regulations and ensure the health and safety of residents in care. LPA Lopez identified herself and was granted entry by a Aurora Lopez, Caretaker. LPA stated the purpose of the visit and reviewed the basic elements of the visit with caretaker Lopez. Facility Manager Siklalic Garcia later arrived and joined the visit.

During today’s visit, LPA toured the facility, observed residents in care, and provided consultation regarding Title 22 requirements. LPA discussed the following regulations: CCR – 87211 Reporting Requirements; CCR – 87633 Hospice Care of Terminally Ill Residents; CCR – 87632 Hospice Care Waiver. The Facility Manager was debriefed on the regulations and there is an understanding of the regulations.

Based on today’s inspection, there were no deficiencies cited at this time in the areas evaluated. An exit interview was conducted with Facility Manager Siklalic Garcia and caretaker Kate Delgadillo. A copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided via email to Facility Manager Garcia and Licensee Quetzalli Kahnis via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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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