Majestic Villa Assisted Living

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

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 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.the state’s words, verbatim · CDSS document, Jan 12, 2023 · control 08-AS-20220401125415

Type of visit: Collateral

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced collateral visit to the facility to obtain records regarding another complaint investigation. LPA Lopez identified herself and stated the purpose of the visit with Angelica Quintero, caregiver, and Quetzalli Kahnis, Administrator, via telephone. During the visit, LPA Lopez requested and obtained relevant documents. No deficiencies were observed during today's visit. An exit interview was conducted, and a copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was provided to Angelica Quintero, caregiver, at the conclusion of the visit. The signature below confirms the receipt of the documents.the state’s words, verbatim · CDSS document, Jan 12, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tammer de los Santos visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Samantha Granados, Caregiver to whom LPA disclosed the purpose of the visit. During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; temperature check initiated at entry for staff, residents, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough / sneeze etiquette, symptom, and transmission awareness; face coverings worn by staff; hand sanitizer readily available; available visitation area; emergency agencies’ contact information visible to staff; and an ample supply of cleaning products and personal protective equipment. LPA gave a copy of Provider Information Notice PIN 22-13-ASC. The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by January 21, 2023. No deficiencies were cited during today’s visit. An exit interview was conducted with Samantha Granados, Caregiver and copies of this report and Licensee Rights (LIC 9058) were provided at the conclusion of the visit. Ms. Granados’ signature on this form acknowledges receipt of the rights and a copy of the report.the state’s words, verbatim · CDSS document, Nov 22, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit to ensure ongoing compliance with laws and regulations and ensure the health and safety of residents in care. LPA Lopez identified herself and was granted entry by a Aurora Lopez, Caretaker. LPA stated the purpose of the visit and reviewed the basic elements of the visit with caretaker Lopez. Facility Manager Siklalic Garcia later arrived and joined the visit. During today’s visit, LPA toured the facility, observed residents in care, and provided consultation regarding Title 22 requirements. LPA discussed the following regulations: CCR – 87211 Reporting Requirements; CCR – 87633 Hospice Care of Terminally Ill Residents; CCR – 87632 Hospice Care Waiver. The Facility Manager was debriefed on the regulations and there is an understanding of the regulations. Based on today’s inspection, there were no deficiencies cited at this time in the areas evaluated. An exit interview was conducted with Facility Manager Siklalic Garcia and caretaker Kate Delgadillo. A copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided via email to Facility Manager Garcia and Licensee Quetzalli Kahnis via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.the state’s words, verbatim · CDSS document, Apr 6, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Aurora Lopez, Caregiver. LPA met with Facility Manager Siklatic Garcia, Facility Manager and discussed the purpose of today’s visit. A tour of the facility was conducted inside and out. LPA, accompanied by Facility Manager conducted a general overall inspection, with specific focus on infection control protocols. During today's inspection LPA observations include the following: Symptom screening procedures for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures. Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Facility Manager. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Facility Manager Garcia and Licensee at the conclusion of the visit. LPA requested Facility Manager or for the Licensee Quetzalli Kahnis to send LPA an electronic message reply confirming receipt of these documents. A current Personnel Report LIC 500, Designation of Administrative Responsibility LIC 308 and an Emergency Disaster Plan LIC 610-E was given to LPA during the visit. Form are also available at www.ccld.ca.gov.the state’s words, verbatim · CDSS document, Nov 15, 2021

The state marks this report as 4 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit at the facility, to complete a health and safety check for clients in care. LPA identified herself and was granted entry by Aurora Lopez, Caregiver. LPA met with Siklatic Garcia, Facility Manager and disclosed the purpose of the visit. The facility self-reported an incident regarding Resident 1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing on November 5, 2021. During today's visit, LPA toured the facility, spoke with staff, residents and Licensee, and reviewed and obtained resident records maintained by the facility. No immediate health or safety concerns were observed. No deficiencies were cited during today’s visit. An exit interview was conducted with Facility Manager Garcia, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), was provided to the Quezalli Khanis Licensee and Facility Manager Garcia via electronic mail. An electronic read receipt confirms the documents were received.the state’s words, verbatim · CDSS document, Nov 15, 2021