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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002875
Report Date: 08/24/2021
Date Signed: 08/24/2021 11:20:21 AM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MESA VERDE RESIDENTIAL CARE CENTERFACILITY NUMBER:
306002875
ADMINISTRATOR:LAWRENCE TALEBIFACILITY TYPE:
740
ADDRESS:673 CENTER STREETTELEPHONE:
(949) 548-5584
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:12CENSUS: 0DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Joseph GaribayTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required Annual - 1 Year visit. LPA arrived at the facility was greeted and granted entry by Staff Mary Crooks. LPA met with Administrator Joseph Garibay and explained the reason of the visit.

LPA Martinez accompanied by Staff Crooks toured the facility, no residents were observed. Per Staff, facility has had no residents since March 2020. LPA explained to Administrator on the importance of following COVID-19 guidelines and measures. Administrator was also reminded facility needs to be in compliance with Title 22 guidelines prior to accepting new residents again.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, this report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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