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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002875
Report Date: 07/10/2024
Date Signed: 07/10/2024 03:27:04 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/10/2024 03:27 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
ORANGE COUNTY RO, 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:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Angelo MunozTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley and conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley entered through the Skilled Nursing side of the Facility (SNF) was greeted by SNF Administrator (AD) Angelo Munoz and explained the reason for the visit.

AD Munoz explained the Assisted Living (AL) portion of the facility does not have any residents and has not operated in about 4 years. AD Munoz introduced me to Staff 1 (S1) who led me on a tour of the AL portion of the facility.

During the tour 7 of 8 rooms and the dining room was opened by S1 and observations were made. LPA Haley did not observe any residents or any signs of any residents living in any of the resident units. While observing rooms, LPA randomly checked hot water temperatures, smoke detectors, and power in 4 of the rooms observed. The facility does have electricity, running water, and the smoke detectors were operational. Hot water temperature was measured in the range of 100.5 – 125.7 degrees F.

During the tour, every room that was observed was being used to store supplies for the SNF. LPA observed, matts, beds, wheelchairs, walkers, sofas, blankets in boxes, boxes of hand sanitizers, boxes of trash liners, and boxes of N95 mask and other items. In the exterior portion of the AL side of the facility are several storage sheds, locked storage areas next to the laundry room, and two large storage containers. Several photos were taken.

After the tour, it was determined the facility is non-operational and a review of the facility profile shows the annual fees are not current. Before the visit ended, LPA Haley informed AD Munoz an informal meeting will be schedule before the end of this month (July 2024) so the Department can be made aware of the facilities plans moving forward. AD Munoz was understanding and receptive regarding the pending informal visit.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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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