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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002875
Report Date: 04/28/2023
Date Signed: 04/28/2023 12:18:00 PM

Unfounded


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
04/21/2023 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230421151442
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:
04/28/2023
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Angelo Munoz, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility lacks care and supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose to conduct a complaint investigation into the above allegation. LPA was greeted by Director of Nursing (DN) Eloisa Batario, BSN, RN and was escorted to meet with Administrator Angelo Munoz and stated the purpose of the visit. During the course of the investigation, LPA requested to obtain copies of records pertinent to Resident 1 (R1) and an interview was conducted with the Administrator. The following was determined:

It was alleged that the facility lacks care and supervision. LPA conducted a tour of the physical plant of the RCFE portion of the facility and observed no residents in care. Per interview with the Admin, facility has not been operating the RCFE portion of the facility. It was also determined that R1 was a patient at the Skilled Nursing portion of the facility. Therefore, this agency has investigated the complaint; and based on the observations made, interview that was conducted, and the records reviewed, the above allegation is deemed UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
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-20230421151442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/28/2023
NARRATIVE
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We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Administrator Angelo Munoz, and a copy of this report including the LIC811 was provided during this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2