<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005533
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:44:42 PM

Document Has Been Signed on 03/11/2025 02:44 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:
03/11/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Florentino PedralvezTIME VISIT/
INSPECTION COMPLETED:
03:00 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) Fred Arias conducted an unannounced case management visit to the facility. LPA was greeted entry and explained the reason for the visit. LPA met with staff member Florentino Pevralvez.

The purpose of today's visit was to conduct a Case Management visit to discuss the present Administrator. Our Regional Office was made aware that the listed Administrator, Mary Jean Catacutan, is no longer the Administrator for the facility. We were made aware Mary Jean Catacutan separated from the facility November 2023. Currently, there is no Administrator working at the facility. Staff member Florentino Pedralvez confirmed the information already known.

LPA spoke with Licensee Shelia Bergum over the phone. Licensee stated she is in the process of interviewing Administrator candidates.

On this visit, LPA toured the facility and conducted an interview with staff Pedralvez.

Based on today's visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with staff representative and a copy of the report was provided along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 03/11/2025 02:44 PM - It Cannot Be Edited


Created By: Fred Arias On 03/11/2025 at 02:25 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: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
87405(a)

1
2
3
4
5
6
7
All facilities shall have a qualified and currently certified administrator...
1
2
3
4
5
6
7
Licensee to hire a qualified administrator by POC due date. Lincesee to submit Administrator paperwork to LPA by POC due date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2