374604353-10-10-2023-18-AS-CGOH-CWGR9F-20231010124929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604353
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:49:37 PM

Document Has Been Signed on 10/10/2023 12:49 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MAJELLA ASSISTED LIVING, LLC		FACILITY NUMBER:	374604353
ADMINISTRATOR:	MORRISON, JIM		FACILITY TYPE:	740
ADDRESS:	2590 MAJELLA RD.		TELEPHONE:	(760) 216-6344
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	12	CENSUS: 10	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Caregiver, Juan Carlo		TIME COMPLETED:	12:49 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 10:33 am. to conduct an unannounced annual visit. LPA met the Caregiver Chima Umolu at the front door and was granted entry. LPA met with Caregiver Juan Carlo Ponce de Leon regarding the visit. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for 12 non-ambulatory residents of which 4 may be bedridden, with 7 non-ambulatory and 3 bedridden resident in care. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility temperature read at 71 degrees. The facility consists of 7 resident bedrooms, and 2 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with tv, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 109 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the laundry room and inaccessible to the resident. The facility and has a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings. Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, additional assessments, and admissions agreement for 4 residents in care. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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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Document Has Been Signed on 10/10/2023 12:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 10 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of resident files, the licensee did not comply with the section cited above in 6 out of 10 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2023 12:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(e)(1)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of posted documents and a request to the caregiver for a copy of the resident roster, the licensee did not comply with the section cited above in 1 out of 1 resident roster (LIC9020) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MAJELLA ASSISTED LIVING, LLC	FACILITY NUMBER: 374604353
	VISIT DATE: 10/10/2023

NARRATIVE

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(Continued from LIC809)

Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has a medication logbook, however no records due to no residents in care, however previous resident records were found, and the facility documented the resident’s medication and in compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 06/11/23. The facility has emergency supply of food and water.
Items of Discussion: Physician’s reports are missing for residents R2, R3, R4, R6, R7, and R8. Residents R4 and R6 are missing identification and emergency information, physician’s reports, physician’s orders, pre-assessments, and admissions agreements. The facility currently does not have a resident roster or LIC9020.
Summary: Deficiencies are being cited per Title 22, Div. 6, Chap 8 and listed on LIC 809-D. An exit interview was conducted, Appeal Rights (LIC 9098) along with a copy of this report was provided to Caregiver Juan Carlo Ponce de Leon and his signature on this form confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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