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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005533
Report Date: 12/14/2022
Date Signed: 12/14/2022 01:18:02 PM


Document Has Been Signed on 12/14/2022 01:18 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 & INLAND A/SC, 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: 3DATE:
12/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Aston Yabut, caregiverTIME COMPLETED:
01:30 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to deliver an amended report for the complaint investigation visit conducted on 11/16/2022. LPA was greeted and granted entry by caregiver Aston Yabut after explaining the purpose of the visit. Administrator Maryjean Catacutan was informed of the visit via voicemail.

The amended report was reviewed and signed by facility representative.

Exit interview conducted and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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