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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005533
Report Date: 07/01/2025
Date Signed: 07/01/2025 03:36:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2025 and conducted by Evaluator William Vanegas
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250422133656
FACILITY NAME:MESA DEL MAR ELDERLY CARE HOMEFACILITY NUMBER:
306005533
ADMINISTRATOR:CYNTHIA SHAYAMUNDAFACILITY TYPE:
740
ADDRESS:1097 CORONA LNTELEPHONE:
(657) 231-9647
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 5DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cynthia ShayamundaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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-Faciltiy does not assist resident with dental hygiene
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA Vanegas was greeted and granted entry to the facility by Administrator (AD) Cynthia Shayamunda after LPA introduced themselves and stated the purpose of the visit. An initial investigation visit was conducted on May 02, 2025. During the visit, LPA Vanegas gathered and reviewed pertinent records pertaining to R1 in regard to the allegations stated above. LPA Vanegas interviewed clients. LPA Vanegas also gathered and reviewed employee files relevant to the allegations being investigated. The investigation in the allegation, facility does not assist resident with dental hygiene, revealed the following. It was alleged that facility staff does not assist resident with dental hygiene. No specific staff members were identified in regard to which one committed the alleged violation. Two of two facility staff were interviewed, and both Staff 1 (S1) and Staff 2 (S2) denied the allegation.

CONTINUED ON LIC9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20250422133656
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/01/2025
NARRATIVE
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The Administrator (AD) reported that they have never witnessed hesitation to assist Resident 1 (R1) with dental hygiene or any other activities of daily living. Resident 2 (R2) reported that they get assistance with activities of daily living every day. R2 reports that they get help with grooming, such as shaving, cleaning dentures, and assistance getting changed. R2 reports that they have never witnessed any hesitation of services to residents in care. Resident 1 (R1) reports that staff does not assist them with dental hygiene, and that they do not treat them well, or provide them with medication every day.

Based on the evidence gathered the allegation, Facility does not assist resident with dental hygiene, is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with AD Cynthia Shayamunda and a copy of the report provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2