306002875-7-29-2020-22-AS-MSTC-BSGU6F-20200814151814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002875
Report Date: 07/29/2020
Date Signed: 07/29/2020 01:36:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/20/2020 and conducted by Evaluator Lydia Martinez

COMPLAINT CONTROL NUMBER: 22-AS-20200720155537

FACILITY NAME:	MESA VERDE RESIDENTIAL CARE CENTER		FACILITY NUMBER:	306002875
ADMINISTRATOR:	LAWRENCE TALEBI		FACILITY TYPE:	740
ADDRESS:	673 CENTER STREET		TELEPHONE:	(949) 548-5584
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	12	CENSUS: 0	DATE:	07/29/2020
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Lawrence Talebi		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

* Facility not able to meet needs of resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Lydia Martinez contacted the facility via telephone to commence a complaint investigation via telephone due to COVID-19 and for pre-cautionary measures. LPA Martinez identified herself and spoke to Facility Administrator, Lawrence Talebi. LPA discussed the purpose of the phone call and explained the allegation.

Based on interviews conducted with Administrator Talebi, Resident 1 (R1) lived at the Mesa Verde Convalescent Hospital from 8/13/2013 to 7/14/2020. R1 has never lived at Mesa Verde Residential Care Center, which is the Assisted Living across the parking lot of the hospital. This was corroborated by a witness. Therefore, the Department determined the complaint to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint.
An exit interview was conducted with Administrator Talebi via telephone and a copy of this report was provided via email. An electronic email read receipt or response to email indicating as received as confirmation. Administrator agrees to send a signed copy by email.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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