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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002875
Report Date: 07/05/2022
Date Signed: 07/05/2022 03:31:36 PM


Document Has Been Signed on 07/05/2022 03:31 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
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:
07/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Joseph GaribayTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced required annual inspection focusing primarily on the Infection Control. At 10:15 am, LPA entered the main lobby through the skilled nursing facility at 661 Center Street to check in and was greeted and granted entry by Certified Nursing Assistant Jacqueline Toxqui Salazar after completing the Coronavirus 2019 (COVID-19) screening procedure. Facility screens and documents temperatures for all visitors on a sign in sheet. The COVID-19 precautionary signs were posted on the front door and in the main lobby. Around 10:20 am, LPA met with Admissions Coordinator (AC) Sophie Cucurull who stated that the facility has not had any residents for approximately 1.5 to 2 years. AC Cucurull stated that there are no active COVID-19 cases as of today, and LPA was instructed to wait in the lobby for Administrator (Admin) Joseph Garibay. LPA met with the Admin at 10:30 am and stated the purpose of the visit. LPA was informed that Admin Lawrence Talebi is no longer associated to the facility, and Admin Joseph Garibay has been the new Administrator since August 31, 2021. The Admin confirmed that there are no residents present and does not have active plans to accept any residents for the time being. In addition, fifteen department head staff including the Admin was not associated to the facility. LPA requested and received a copy of the Personnel Report LIC 500, and fourteen out of the fifteen staff will be associated once the Guardian account is created. Due to an exemption denial of Staff 2, Staff 2 will not be working in the assisted living portion of the facility until cleared effective today. LPA provided the number to Sacramento to Staff 2 to ensure eligibility with the Department.

At 11:43 am, LPA toured the interior and exterior portions of the facility with Certified Nursing Assistant (CNA) Yesica Villa and Housekeeping Supervisor Luz M. Sanchez. Facility has a total of seven apartments. Apartments 1 to 5 have two bedrooms per apartment, and apartments 5 to 7 are private. Smoke and carbon monoxides tested operational, and the restrooms appeared to be in good repair. Hot water measured between the ranges of 95.7 to 113.0 degrees Fahrenheit in eleven restrooms. LPA did not observe any residents in the facility, and the facility is currently being used as a storage.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 306002875
VISIT DATE: 07/05/2022
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LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility had back-up emergency food stored in the kitchen and the water supply stored in the outdoor water heater closet. The First Aid Kit was unavailable due to not having residents at this time.

LPA consulted the following: the importance of associating any staff person, volunteer, or employee who has contact with the residents including the department head staff, the water in the restrooms providing hot water in between the ranges of 105.0 to 120.0 degrees Fahrenheit, to maintain in compliance with the annual licensing fees, and to report to the Department once the facility is ready to accept new residents in the assisted living.



LPA reviewed the approved COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the correction. An exit interview was conducted with Administrator Joseph Garibay, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC809 (FAS) - (06/04)
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