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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804455
Report Date: 05/06/2024
Date Signed: 05/06/2024 04:24:12 PM

Document Has Been Signed on 05/06/2024 04:24 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MESA BOARD AND CAREFACILITY NUMBER:
370804455
ADMINISTRATOR/
DIRECTOR:		MESA, CECILIAFACILITY TYPE:
740
ADDRESS:3865 DARWIN AVENUETELEPHONE:
(619) 934-9144
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY: 6CENSUS: 2DATE:
05/06/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Administrator, Cecilia MesaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to complete the Required 1-Year Visit from May 3, 2024. LPA was greeted by, Caregiver, Melvin Mesa. LPA met and discussed the purpose of the visit with the Administrator, Mesa. All staff present have a current criminal record clearance.

Licensee applied for increased capacity from two (2) non-ambulatory residents to four (4) non-ambulatory residents. Fire Clearance was approved on June 23, 2022, for a total capacity of six (6) of whom four (4) may be non-ambulatory. As of today, there were two (2) residents in care of whom one (1) was non-ambulatory. LPA toured the facility and discussed with the Administrator regarding operation.

On May 3, 2024, LPA, accompanied by Administrator, Mesa, toured the interior and exterior of the facility and inspected each room. The facility was in good repair. Some areas of the facility, bathrooms, and kitchen were observed with clutter, and the floors and area rugs were dirty. Some areas inside and outside the facility were observed with clutter, however, hallways were free of obstruction and slip hazards. No immediate safety risk was observed. Residents’ bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

There were at least 2 days of perishable food, and at least 7 days of non-perishable food present, all safely stored. The food sitting on the kitchen counter accessible to residents contained items with expiration dates dating back to 2021 and 2022.

(Continue at LIC 809C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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 6
Document Has Been Signed on 05/06/2024 04:24 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 05/06/2024 at 01:45 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MESA BOARD AND CARE
FACILITY NUMBER: 370804455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff interview and record review, the licensee did not comply with the section cited above. Licensee did not have current liability insurance covering injury for residents in care (R1 and R2). Which which poses a potential safety risk to two (2) of two (2) persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Licensee agreed to provide liability insurance and submit proof of insurance by POC date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and staff interview, the licensee did not comply with the section cited above. Licensee did not dispose of expired food from the pantry and refigerator for residents in care, R1 and R2. Which posed a potential health risk to two (2) of two (2) persons in care.
POC Due Date: 05/06/2024
Plan of Correction
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Licensee disposed of all expired food during visit conducted on May 3, 2024. LPA verified food pantry and refrigerator during today's visit. No expired food was observed. POC has been satisfied.
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:Jennifer Lott
LICENSING EVALUATOR NAME:Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/06/2024 04:24 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 05/06/2024 at 01:45 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MESA BOARD AND CARE
FACILITY NUMBER: 370804455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(1)
Incidental Medical and Dental Care Services
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not obtain medical assessments for residents in care, physician's reports for Residents R1 and R2 were outdated. Which poses a potential health risk to persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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Licensee agreed to obtain medical assessments for residents in care and obtain an updated Physician's Reports bor residents in care annually or when change in condition. Licensee will provide proof of documentation by POC date.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, staff interviews and records review, the licensee did not comply with the section cited above in one (1) out of two (2) residents in care. Which posed a potential health risk to one (1) of two (2) persons in care.
POC Due Date: 05/06/2024
Plan of Correction
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During the visint conducted on 5/3/2024, Licensee agreed to store all medications for both residents in the designated centrally storage area which is maintained locked and not accessible to residents in care. POC has been satisfied.
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:Jennifer Lott
LICENSING EVALUATOR NAME:Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/06/2024 04:24 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 05/06/2024 at 01:46 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MESA BOARD AND CARE
FACILITY NUMBER: 370804455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, staff interview and records review , the licensee did not comply with the section cited above in two (2) out of two (2) residents, R1 and R2. Which posed a potential health risk to two (2) of two (2) persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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Licensee agreed to maintain medication administration records for residents in care. Licensee agree to provide additional training on medication managment. Licensee will provide proof of training by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, records review and staff interviews, the licensee did not comply with the section cited above. Licensee did not conduct ememrgency drills since 2014. Which poses a potential safety risk for two (2) of two (2) persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee agreed to conduct emergency dirlls at least quarterly and provide documentation of the next drill conducted by POC date. Licensee agreed to conduct additional training on emergency/evacuation procedures with all staff and submit proof of training conducted by POC date.
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:Jennifer Lott
LICENSING EVALUATOR NAME:Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/06/2024 04:24 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 05/06/2024 at 01:46 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MESA BOARD AND CARE
FACILITY NUMBER: 370804455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(3)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff interview and record review, the licensee did not comply with the section cited above. Licensee did not have a record of the medications for resident R1. Which posed a potential health risk to persons one (1) of two (2) residents in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee agreed to maintain records of all medications prescribed for residents in care. Licensee agreed to conduct additional training on medication managment. Licensee agreed to submit proof of training conducted by POC 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:Jennifer Lott
LICENSING EVALUATOR NAME:Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MESA BOARD AND CARE
FACILITY NUMBER: 370804455
VISIT DATE: 05/06/2024
NARRATIVE
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(continue from LIC809)
The licensee discarded expired food during the visit. The refrigerator was observed with spoiled food in unmarked containers which were also discarded during the visit. It was observed that cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, however, the medication for one resident was not centrally located in the designated storage area. In addition, it was observed that old medication had not been discarded as required.

The facility had no pools of water on the premises. Per staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. The facility fire extinguisher was serviced in April 2024. First aid kit(s) were observed to be complete and accessible as required. Required licensing postings were observed in visible areas of the facility. The room temperature in the facility was comfortable at 70 degrees.

LPA interviewed staff and residents and reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files that LPA reviewed contained the required documents. However, the residents’ Physician’s Reports and the Appraisal/Needs and Services Plan were not updated as required by Title 22 regulations. Confidential records were stored in locked areas.

During today’s visit, LPA observed via measurement with a thermometer device, that hot water temperature at taps accessible to clients complied with regulations. Water from the kitchen sink reached 110 F. The licensee did not have proof of current/active business liability insurance.

Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the licensee.

An exit interview was conducted with Administrator, Cecilia Mesa, to whom a copy of this report, LIC 809D and LIC811 and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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