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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005533
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:46:17 PM


Document Has Been Signed on 11/04/2022 12:46 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 DEL MAR ELDERLY CARE HOMEFACILITY NUMBER:
306005533
ADMINISTRATOR:MARY JEAN CATACUTANFACILITY TYPE:
740
ADDRESS:1097 CORONA LNTELEPHONE:
(657) 210-4719
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 5DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Mary Jean CatacutanTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Mesa Del Mar Elderly Care Home to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 11:55am, LPA Cho was greeted and granted entry by Caregiver Ernesto Rodriguez. Also present was Caregiver Mikko Mallari. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a check-in station that required a COVID-19 screening for all visitors which had temperatures documented on a sign-in sheet. LPA observed the required COVID-19 precautionary signs posted on the front entrance and throughout the facility. The Complaint Poster (PUB475) met the Department size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently five residents living in the facility of which four are receiving hospice care. The Administrator's Certificate for Mary Jean Catacutan expires on 08/02/2023.

At 12:09pm, LPA Cho conducted a tour of the physical plant with Caregiver Mikko Mallari. There are a total of three resident bedrooms and one resident bathroom. There is one private staff bedroom and staff bathroom. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and slip mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked with hand soaps and paper towels. LPA observed a hand washing sign in the bathroom. The hot water temperature measured at 111.0 degrees Fahrenheit in resident Bathroom #1. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and purchased on 05/01/2022. Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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 DEL MAR ELDERLY CARE HOME
FACILITY NUMBER: 306005533
VISIT DATE: 11/04/2022
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The exit gates were self-closing and self-latching. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.

Administrator Mary Jean Catacutan arrived approximately 12:34pm to be present at the exit interview.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Mary Jean Catacutan, 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: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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