306005533-11-29-2022-22-AS-SSAS-CM54T4-20221214182231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005533
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:44:38 PM

Substantiated

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
11/10/2022 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221110171432

FACILITY NAME:	MESA DEL MAR ELDERLY CARE HOME		FACILITY NUMBER:	306005533
ADMINISTRATOR:	MARY JEAN CATACUTAN		FACILITY TYPE:	740
ADDRESS:	1097 CORONA LN		TELEPHONE:	(657) 210-4719
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 4	DATE:	11/29/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mary Jean Catacutan, administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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1/ Facility did not provide adequate supervision to resident in care.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of continuing the investigation into the allegation listed above, update and deliver findings accordingly based on the additional evidence gathered. LPA was greeted and granted entry by caregiving staff after stating the purpose of the visit. Mary Jean Catacutan, administrator was notified of the visit and arrived shortly afterward to assist.

LPA requested and obtained access to resident R1's records on file at the facility, which were reviewed and copied during the visit.

LPA additionally interviewed the facility's administrator and two caregivers present during the visit. A phone interview was conducted with another cargeiver who was present on 10/23/2022.

CONTINUED ON LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221110171432

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 DEL MAR ELDERLY CARE HOME	FACILITY NUMBER: 306005533
	VISIT DATE: 11/29/2022

NARRATIVE

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CONTINUED FROM FORM LIC9099

Based on the staff interviews conducted and special incident report provided by the facility, during the night of 10/23/2022 between the hours of 3:00am and 5:00am, resident R1 was able to leave the facility unsupervised and without the knowledge of facility staff present while staff member S1 was attending to another resident. Sound alarms are observed by LPA to be present at the facility during the visit but it is alleged that the volume was insufficient to adequately alert S1 of the resident's exit from the physical plant when it occurred. Resident was then found by first responders and taken to Hoag Hospital before being released back to the facility at approximately 11:30am the same day.

Following the incident, a meeting was initiated with R1's Durable Power Of Attorney (DPOA) to update the safety measures in place. A review of staff records confirmed that all facility staff have received appropriate dementia training. The facility has at least one night staff person awake and on duty to tend to residents requiring night supervision, with one additional staff on call and present on the facility's premises. The volume of the auditory alarms has been increased. A neurology appointment was set up for resident R1. Facility staff has additionally requested an updated medical assessment by both the resident's primary care provider and neurologist in order to determine whether the current placement at the facility is still adequate in light of the increased needs of care and supervision displayed by R1.

While attempts at ensuring the resident's health and safety are confirmed to have been made by facility staff, these attempts fell short of their intended goal, resulting in R1's leaving the premises unsupervised.

Based on the interviews conducted, observations made during the two complaint investigation visits and a review of available staff and resident records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency to the California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached form LIC 9099D and a civil penalty of $500 is being assessed.

An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221110171432

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 DEL MAR ELDERLY CARE HOME	FACILITY NUMBER: 306005533
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/30/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services-Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code. Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident's	1 2 3 4 5 6 7	Licensee will continue to ensure adequate training and ongoing supervision of resident R1 and other individuals in care as well as continue assessing whether the current placement is appropriate given the evolving needs of resident R1
	8 9 10 11 12 13 14	physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by: On 10/23/22 R1 left the facility unattended without staff being aware. This poses an immediate health and safety risk to residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC9099 (FAS) - (06/04)

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