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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005533
Report Date: 02/11/2025
Date Signed: 02/11/2025 05:37:08 PM

Document Has Been Signed on 02/11/2025 05:37 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MESA DEL MAR ELDERLY CARE HOMEFACILITY NUMBER:
306005533
ADMINISTRATOR/
DIRECTOR:		MARY JEAN CATACUTANFACILITY TYPE:
740
ADDRESS:1097 CORONA LNTELEPHONE:
(657) 210-4719
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 6DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:13 PM
MET WITH:Florentino Pedralvez TIME VISIT/
INSPECTION COMPLETED:
05:47 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. Facility has 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, 2 car garage and 3 storage sheds in the backyard. Facility is licensed for 6 non-ambulatory residents with a hospice waiver for 4. LPA and staff toured the facility. The Administrator's certificate expires on August 2, 2025. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA observed the living room has a fire place that is screened. LPA observed a wall outlet in the living room that did not have a protective plate over it, the outlet wires are visible. The living room has a TV, 4 reclining chairs, 1 chair and a love seat. LPA observed both bathrooms are clean and operational. Hot water measured 119.6 degrees Fahrenheit in both bathrooms. LPA observed all the resident rooms had the required furnishings. All bedrooms in the facility have an exit and have fire clearance for non-ambulatory residents. LPA observed that in bedrooms 3 and 4 the exit doors were locked and could not be opened by residents in case of an emergency. Staff unlocked the doors during the visit. LPA toured the kitchen. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPA observed the sharp objects are kept locked under the kitchen sink. LPA observed the cleaning supplies are kept locked in the garage. LPA observed medications are kept locked in the hall closet. LPA observed a 3 day emergency supply of food and water stored in the garage. LPA observed liquid cleaner stored outside of it's original container. Purple cleaner (Fabuloso) was stored in 3 Windex bottles and had no additional labels to identify their contents. Smoke/carbon monoxide detectors tested operational. LPA and staff toured the backyard. Both exit gates on each side of the house are operational. LPA inspected all 3 storage sheds. All 3 sheds are kept locked. LPA observed old furniture and supplies stored in the sheds. No bodies of water observed in the backyard. There is a table with an umbrella and chairs to sit outside. No obstacles or hazards observed in the backyard. LPA reviewed 6 resident records and medications. No discrepancies observed. LPA reviewed 2 staff files. Both staff members are background cleared and associated to the facility. Both staff have all the required training and no discrepancies observed in their files.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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 02/11/2025 05:37 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 02/11/2025 at 04:16 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MESA DEL MAR ELDERLY CARE HOME
FACILITY NUMBER: 306005533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA observed the emergency exit in bedrooms 3 and 4 were locked and could not be opened by residents which poses an immediate safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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Licensee agrees to keep the emergency exits in all the resident rooms unlocked from the inside of the facility.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2025 05:37 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 02/11/2025 at 05:10 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MESA DEL MAR ELDERLY CARE HOME
FACILITY NUMBER: 306005533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above< LPA observed the outlet in the living room does not have a protective plate and the outlet wires are visible which poses a potential safety rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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Licensee agrees to install a new protective plate over the exposed outlet by the POC due 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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MESA DEL MAR ELDERLY CARE HOME
FACILITY NUMBER: 306005533
VISIT DATE: 02/11/2025
NARRATIVE
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Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809Ds. Immediate civil penalty is being assessed due to fire safety deficiencies. See LIC421IM. An exit interview was conducted and copies of this report, deficiency pages, civil penalty assessment, appeal rights, and cited regulations were provided to the facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2025 05:37 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 02/11/2025 at 05:23 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MESA DEL MAR ELDERLY CARE HOME
FACILITY NUMBER: 306005533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(2)(B)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (2) Any items in subsection (a)(1) that are transferred from their original container to another container shall have a legible label that indicates: (B) Any product warnings indicated on the original label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA observed liquid cleaner stored outside of it's original container. Purple cleaner (Fabuloso) was stored in 3 Windex bottles and had not additional labels to identify their contents. which posea potential health and safety risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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Licensees agrees to have all cleaners stored in their original container. Licensee to submit a statement of understanding for regulation 87309. Licensee to submit statement of understanding by POC due 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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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