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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604082
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:40:38 PM


Document Has Been Signed on 01/12/2023 02:40 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:SIKLALIC GARCIAFACILITY TYPE:
740
ADDRESS:1910 WOODSIDE DRTELEPHONE:
(442) 231-8517
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY:6CENSUS: 5DATE:
01/12/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Angelica Quintero, CaregiverTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced collateral visit to the facility to obtain records regarding another complaint investigation. LPA Lopez identified herself and stated the purpose of the visit with Angelica Quintero, caregiver, and Quetzalli Kahnis, Administrator, via telephone.

During the visit, LPA Lopez requested and obtained relevant documents. No deficiencies were observed during today's visit.

An exit interview was conducted, and a copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was provided to Angelica Quintero, caregiver, at the conclusion of the visit. The signature below confirms the receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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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