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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604385
Report Date: 05/08/2024
Date Signed: 05/08/2024 10:35:54 AM


Document Has Been Signed on 05/08/2024 10:35 AM - 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 OF SAN MARCOSFACILITY NUMBER:
374604385
ADMINISTRATOR:MORRISON, JIMFACILITY TYPE:
740
ADDRESS:558 SMILAX RD.TELEPHONE:
(760) 734-5786
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:11CENSUS: 10DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:ADMINISTRATOR, JIM MORRISONTIME COMPLETED:
10:48 AM
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On May 08, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Jim Morrison. The facility file review was conducted in the Regional Office and additional forms were reviewed and requested on site. The facility is licensed for 11 Elderly Adults and is operating at a capacity of 10 Elderly Adults (740).

LPA Mixson toured the facility along with the Administrator and inspected the facility inside and outside. There are no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home located at 558 Smilax Rd. San Marcos, CA. 92078.

Physical Plant: The facility phone number is (760) 734-5786 and it is operable. The LPA observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

Medications: Were locked and inaccessible to residents in care, and there were a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit, and there were safety lights for night.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharps are locked.

Care & Supervision: Facility has sufficient staff, two staff on site at the time of this visit and the administrator arrived shortly after.

Records Review: The LPA reviewed resident and staff files, conducted staff and resident interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was discussed and provided to the Administrator, Jim Morrison.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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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