306005533-5-7-2024-22-AS-LMOA-D5SU8J-20240531152136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005533
Report Date: 05/07/2024
Date Signed: 05/07/2024 01:17:42 PM

Unsubstantiated

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
05/01/2024 and conducted by Evaluator Jerome Haley

COMPLAINT CONTROL NUMBER: 22-AS-20240501093702

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: 5	DATE:	05/07/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Shelia Bergum Florentino Pedralvez		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are not providing resident's records to responsible person
Facility staff falsified resident's records

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding a complaint that was filed May 1, 2024. LPA Haley was greeted by staff and explained the reason for the visit.
Before starting interviews, LPA Haley was lead on a brief tour of the facility by staff.

Regarding the allegation: Facility staff are not providing resident's records to responsible person.
3 of 4 individuals denied the allegation or were not able to support the allegation as reported.
During an interview with Staff 1 (S1), it was reported, requested documents were provided more than once to the requesting party. According to S1, the documents were provided more than a years ago. S1 says the documents were sent to the requesting party by the mail.

Regarding the allegation: Facility staff falsified resident's records.
3 of 4 individuals denied the allegation or were not able to support the allegation as reported.
Staff 1 (S1) and Staff 2 (S2) both denied any knowledge of any documents being falsified.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

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-20240501093702

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: 05/07/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

When the RP was asked if there are any copies of the falsified documents, the RP said maybe in a storage facility.

Based on the information gathered during the investigation through interviews and document review the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute an alleged violation occurred; therefore, the allegations are deemed Unsubstantiated.

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

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2