306005533-7-10-2024-22-AS-LMOA-D7Q4RH-20240731191957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005533
Report Date: 07/10/2024
Date Signed: 07/10/2024 12:25:46 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
07/01/2024 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240701094019

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:	07/10/2024
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Shelia Bergum		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Unlawful eviction.
Incomplete documents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to begin the investigation regarding a complaint that was received July 1, 2024. LPA was greeted by staff and explained the reason for the visit before entering the facility. The complaint investigation consisted of interviews with facility staff, and document review.

Regarding the allegation: Unlawful eviction.
2 of 2 staff interviewed confirmed Resident 1 (R1) was not allowed to return to the facility after being sent to the hospital. According to Staff 1 (S1), R1’s daughter was called, and told to pick up R1 from the hospital. R1’s daughter was informed the resident could not return because R1 could not administer their own insulin and the facility does not have a nurse available to administer the insulin injections. According to Staff 2 (S2), R1 was not allowed to return to the facility because the facility was misled and told R1 could administer insulin. S2 says that was untrue, and staff realized this after about two days.
Continued on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240701094019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MESA DEL MAR ELDERLY CARE HOME	FACILITY NUMBER: 306005533
	VISIT DATE: 07/10/2024

NARRATIVE

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Regarding the allegation: Incomplete documents.
Based on document review and interview confirmation from S1, it was discovered the Admission Agreement was not properly completed during the admission process. S1 stated R1’s daughter did not complete the admission packet given to her until a couple days before R1 was sent to the hospital. S1 says, we didn’t have a contract or exchange any money. A review of the Admission Agreement shows it was not signed or dated by the licensee or a representative of the licensee.

Based on the evidence gathered during interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.

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

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20240701094019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 07/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/11/2024 Section Cited CCR 87224(c)	1 2 3 4 5 6 7	87224 Eviction Procedures (c) The licensee shall, in addition to either serving the required thirty (30) days notice, sixty (60) days notice or... three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person.	1 2 3 4 5 6 7	The licensee agrees to read and review regulation section 87224 on Eviction Procedures. The licensee will send a signed statement of acknowledgement and understanding to LPA Haley by the close of business on the POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interview confirmation, the licensee did not ensure the eviction process was followed according to regulation guidelines which poses an immediately personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 07/11/2024 Section Cited CCR 87507(c)	1 2 3 4 5 6 7	87507 Admission Agreements (c) Admission agreements shall be signed and dated... by the resident or the resident’s representative... and the licensee or the licensee’s designated representative... Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.	1 2 3 4 5 6 7	The licensee agrees to read and review regulation section 87507-Admission Agreements. The licensee will send a signed statement of acknowledgement and understanding to LPA Haley by the close of business on the POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based interview confirmation and document review, the licensee did not ensure the admission agreement was properly completed and signed by the licensee or a designated representative.	8 9 10 11 12 13 14

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: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

LIC9099 (FAS) - (06/04)

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