374604082-1-12-2023-08-AS-DPOL-CNLVL4-20230131153119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604082
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:09:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2022 and conducted by Evaluator Carmen Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220401125415

FACILITY NAME:	MAJESTIC VILLA ASSISTED LIVING		FACILITY NUMBER:	374604082
ADMINISTRATOR:	KAHNIS, QUETZALLI		FACILITY TYPE:	740
ADDRESS:	1910 WOODSIDE DR		TELEPHONE:	(442) 231-8517
CITY:	EL CENTRO	STATE: CA	ZIP CODE:	92243
CAPACITY:	6	CENSUS: 6	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	11:26 AM
MET WITH:	Angelica Quintero, Caregiver		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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- Staff did not allow resident visitation.
- Staff did not provide authorized representative resident records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Angelica Quintero, caregiver. LPA stated the purpose of the visit and reviewed the findings of the complaint with caregiver Quintero and via telephone with Kevin Kahnis and Quetzalli Kahnis, Administrator's.

The Department’s investigation consisted of interviews with staff and outside sources, and records reviewed of relevant documents pertinent to this investigation. On April 1, 2022, it was alleged that the facility did not allow resident visitation. It was also alleged that staff did not provide authorized representative resident records.

On April1, 2022, it was alleged that facility staff did not allow Resident #1 (R1) visitation. Interviews with staff determined a visitor was granted entry to visit R1 but was later asked by staff to leave the facility due to potential safety concerns. Staff statements indicated the visitor in question had misrepresented themselves as a “nurse”.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220401125415

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 374604082
	VISIT DATE: 01/12/2023

NARRATIVE

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R1 was not able to identify the visitor by name. Review of facility visitation log showed the individual in question signed in as a private visitor and was not a medical professional. Additional source documents determined the facility had subsequent negative contact with this individual. Staff concerns related to disruptive visitation were also reported to the Department during this time period. There was insufficient evidence to support the allegation that staff did not allow R1 visitation.

It was also alleged that staff did not provide records to a resident’s authorized representative. Specifically, it was alleged that staff refused to provide a facility notebook that contained internal care annotations for Resident #2 (R2). There were inconsistent statements from outside sources regarding who had power of attorney for R2 and could access this information. However, records review determined the names of specific individuals who were designed as the resident’s authorized representatives on file. Neither of these individuals had made the request to staff to have access to the internal facility notebook concerning R2. No additional documentation was provided during the investigation. There was insufficient evidence to support the allegation that staff did not provide records to R2’s authorized representative.

Based on evidence obtained from interviews and records review, there was insufficient evidence to support either allegation. The above allegations were therefore deemed to be unsubstantiated since the preponderance of evidence standard was not met. An exit interview was conducted with caregiver Quintero and Administrator's Kahnis' and a copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was provided at the conclusion of the visit. The signature below confirms receipt of these documents.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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