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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604353
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:17:36 PM

Document Has Been Signed on 10/16/2024 02:17 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAJELLA ASSISTED LIVING, LLCFACILITY NUMBER:
374604353
ADMINISTRATOR/
DIRECTOR:		MORRISON, JIMFACILITY TYPE:
740
ADDRESS:2590 MAJELLA RD.TELEPHONE:
(760) 216-6344
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 12CENSUS: 12DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:58 AM
MET WITH:HOUSE MANAGER, JUAN PONCE DELEONTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On October 16, 2024, Licensing Program Analyst (LPA), Venus Mixson, made an unannounced visit to the facility for the purpose of conducting the Required Annual inspection, and met with House Manager, Juan Ponce Deleon. LPA introduced herself and stated the purpose for the visit. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site.

PHYSICAL PLANT: Facility is located at 2590 Majella RD. Vista, CA. 92084 and the land line phone number is (760) 216-6344, and is operable. Facility is licensed for six Elderly Adults for a (740) facility type and is operating at one which is within the conditions and limitations of the license. Outdoor and indoor passageways are free of obstruction and debris at the time of this visit. There were no pools or bodies of water observed on the property at this time. According to staff, there are no known weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to residents in care. The facility temperature was within in regulations for this time of day and the season, and there was sufficient lighting throughout the facility.

Hot Water temperature: was tested and found to be within regulations. LPA Mixson observed the Fire extinguisher located in laundry area located off the kitchen and has proper inspection tag. Last inspected by 1-800-Fire Hawk, on 10/03/2024. The smoke and carbon monoxide alarms were in the green. The interior and exterior areas of the home were observed to be clean and organized.

FOOD SERVICE: There was a variety of food types which were sealed and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient for the number of residents in care. The kitchen was observed to be clean, neat, and orderly. Additionally, kitchen was free of orders and any signs of pest. LPA observed the required two-day supply of perishable and seven-day supply of non-perishable food items.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAJELLA ASSISTED LIVING, LLC
FACILITY NUMBER: 374604353
VISIT DATE: 10/16/2024
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Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate with an expiration date of 07/16/2025.

Records Reviewed and Resident/Staff Files: LPA reviewed one staff file and reviewed the facility's staff schedule. The staff file reviewed has criminal clearance and updated training along with First Aid Certification. One resident file was reviewed and possessed all required paperwork.



MEDICATION: Medications were reviewed for one resident in care. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care. Medications and medication documentation was observed to be well organized and monitored.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.


There were TA provided for missing hours of training, per Title 22, Division 6 of the California Code of Regulations at this time.



An exit interview was conducted where a copy of this report was discussed and given to House Manager, Juan Ponce Deleon.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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Document Has Been Signed on 10/16/2024 02:17 PM - It Cannot Be Edited


Created By: Venus Mixson On 10/16/2024 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MAJELLA ASSISTED LIVING, LLC
FACILITY NUMBER: 374604353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based (interview) (record review)], the licensee did not comply with the section cited above in (1) out of [1] [STAFF FILES )] [DID NOT CONTAIN THE REQUIRED STAFF ANNUAL TRAINING ON DEMENTIA CARE] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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ADMINISTRATOR INFORMED LPA THEY WOULD CONDUCT THE ADDITIONAL HOURS OF TRAINING AND EMAIL OR FAX THE REQUIRED FORMS TO THE RO BY THE CLOSE OF BUSINESS ON THE LISTED TIME AND DATE.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Venus Mixson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


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