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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409400
Report Date: 07/08/2025
Date Signed: 07/09/2025 09:37:49 AM

Document Has Been Signed on 07/09/2025 09:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MESA VERDE HOMEFACILITY NUMBER:
336409400
ADMINISTRATOR/
DIRECTOR:		MARYROSE KHANFACILITY TYPE:
735
ADDRESS:29656 MESA VERDE CIRCLETELEPHONE:
(951) 309-3733
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 6CENSUS: 6DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Administrator, MaryRose KhanTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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On 7/8/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced one (1) year required visit. LPA was granted entry by Administrator, Mary Rose Khan, who was informed of the purpose of visit. At the time of the inspection, there was one (1) client present and (5) five other clients were out at day program. All staff were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA Flores observed the following during today's visit:

LPA Flores conducted a tour of the facility and observed the physical plant is a two-story structure consisting of eight (8) bedrooms and three (3) bathrooms. The facility has a formal dining rooms, kitchen, living room, staff office, garage, and a gated backyard. Indoor and outdoor passageways were free of obstruction. There were no bodies of water located on the property. The facility has more than a two (2) day supply of perishable food and seven (7) day supply of non-perishable foods. Dishes and utensils were in sufficient supply and in good repair. Garage had an additional refrigerator and freezer with sufficient amount of food. Knives and other sharp items are located in a locked cabinet. During the tour of the kitchen, LPA observed insects inside two kitchen cabinet. Resident bedrooms had the required bedding, furniture, and lighting. The smoke and carbon monoxide detectors were tested and were observed to be operable. Centrally stored medication was observed in a locked cabinet. According to Administrator, Mary Rose Khan, there are no firearms or ammunition on the premises.


(Continue to LIC809C)

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/09/2025 09:37 AM - It Cannot Be Edited


Created By: Valerie Flores On 07/08/2025 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MESA VERDE HOME
FACILITY NUMBER: 336409400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not creating an infection control plan as outlined in Title 22, section 85095 which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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Administrator Mary Rose stated she will review Title 22, section 85095.5, Infection Control Plan, and create an infection control plan to reflect Title 22 regulations. The proof will be submited via email to LPA by 8/8/2025.
Type B
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one (1) out of six (6) residents being non-ambulatory. Per the license given by Community Care Licensing (CCL), the facility is licensed for ambulatory residents only which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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Administrator will begin the process of updating their license to reflect the retention of non-ambulatory residents tomorrow, 7/8/2025. Administrator will speak with LPA via telephone for additional guidance on 7/8/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Rikesha Stamps
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2025 09:37 AM - It Cannot Be Edited


Created By: Valerie Flores On 07/08/2025 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MESA VERDE HOME
FACILITY NUMBER: 336409400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in two (2) out of four (4) facility staff did not have a health screening on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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Administrator Mary Rose stated she will have staff 1 (S1) and staff 2 (S2) complete a health screening by 7/29/2025 and will email proof of completion via email by close of business day on 7/29/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Rikesha Stamps
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MESA VERDE HOME
FACILITY NUMBER: 336409400
VISIT DATE: 07/08/2025
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(Continuation from LIC 809)
Staff record review did not retain record of a health screening being conducted for two (2) out of four (4) staff. Client files included but are not limited to signed admission agreements, placement, personal rights, and physician reports. After review physician reports for six (6) clients, LPA observed one (1) out of (6) six resident did not reflect the correct ambulatory status for Client 1 (C1). Facility file review did not include a required infection control plan. Facility sketch, LTCO, CCL complaint poster, and facility License is posted on walls throughout the facility.

Based on the information received and observed during today's visit, three (3) deficiencies will be issued per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted, and a copy of this report along with appeal rights was reviewed and provided to the Administrator, Mary Rose.
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
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