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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604353
Report Date: 11/22/2023
Date Signed: 11/22/2023 12:24:46 PM

Document Has Been Signed on 11/22/2023 12:24 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAJELLA ASSISTED LIVING, LLCFACILITY NUMBER:
374604353
ADMINISTRATOR:MORRISON, JIMFACILITY TYPE:
740
ADDRESS:2590 MAJELLA RD.TELEPHONE:
(760) 216-6344
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 12CENSUS: 9DATE:
11/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Juan Carlos Ponce - House ManagerTIME COMPLETED:
12:37 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit regarding complaint 18-AS-20231115154544. LPA was granted entry and met with House Manager Juan Carlos Ponce De Leon.

LPA conducted a health and safety check and toured the home, conducted interviews, and record review.

LPA conducted a health and safety check and found based on record review, observations, and interviews, that Staff Two (S2) were not associated to work at this facility. Civil penalties will be issued.

LPA's interview with Staff One (S1) and Administrator Jim Morrison revealed Resident One (R1) had passed away on 11/04/2023. Licensee did not report R1's death to the department per Title 22 regulations and a deficiency will be issued along with a plan of correction. The department's last incident report or death report that was received from the licensee was on 07/21/2021.

An exit interview was conducted where a copy of this report, deficiency page, and appeal rights was provided to House Manager Juan Carlos Ponce De Leon.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/22/2023 12:24 PM - It Cannot Be Edited


Created By: Sara Martinez On 11/22/2023 at 11:47 AM
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: 11/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2023
Section Cited

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87355 CRIMINAL RECORD CLEARANCE (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...
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his requirement is not met as evidenced by: Based on file review & interview, the licensee did not ensure S2 were associated to the facility prior to working. Which is an immediete health and safety risk and/or personal rights violation to residents in care.
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Type B
12/01/2023
Section Cited

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency...within 7 days of the occurrence of any of the events...
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This requirement was not met, as evidenced by: Based on interviews and record review, the Licensee did not ensure R1's death was reported to the Department within 7 days of the occurrence.This poses a potential risk to the health, safety or personal rights of the residents in care.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023


LIC809 (FAS) - (06/04)
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