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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804455
Report Date: 05/06/2024
Date Signed: 05/06/2024 04:17:42 PM


Document Has Been Signed on 05/06/2024 04:17 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:MESA BOARD AND CAREFACILITY NUMBER:
370804455
ADMINISTRATOR:MESA, CECILIAFACILITY TYPE:
740
ADDRESS:3865 DARWIN AVENUETELEPHONE:
(619) 934-9144
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY:6CENSUS: 2DATE:
05/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator, Cecilia MesaTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Marisela Garcia-Centeno, conducted a case management visit to cite deficiencies observed during an annual inspection visit on May 3, 2024. LPA was greeted by Caregiver, Melvin Mesa. LPA met with Administrator, Cecilia Mesa to whom she idenify herself and disclosed the purpose of the visit.

On Friday, May 3, 2024, during an annual visit it was disclosed that a resident (R1) [an LIC 811 Confidential Names List was provided to staff to identify the resident] expired on February 6, 2024 after an unwitnessed fall incident. Licensee did not submit an Death Report LIC624A as required by Title 22 regulations. Per California Code of Regulations, Title 22. deficiencies were cited in an LIC 809D.

An exit interview was conducted with Administrator, Cecilia Mesa to whom a copy of this report, LIC 809D, LIC811 Confidential Names list and Licensee's Rights (LIC 9058 03/22) were provided at the conclusion of the visit.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024
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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Document Has Been Signed on 05/06/2024 04:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: MESA BOARD AND CARE
FACILITY NUMBER: 370804455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
87811(a)(1)(A)

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87211(a)(1)(A) Reporting Requirements. (a) Each licensee shall furnish a written report to the licensing agency and to the person responsible for the resident within seven days of the occurrence of a death of any resident from any cause regardless of where the death occurred. This requirement was not met.
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Licensee agreed to submit an incident report along with death report for R1 by POC date. In addition, LIcensee agreed to conduct additional training on reporting requirements by a third party provider. LIcensee will submit supporting documentation of training conducted or scheduled by POC date 5/10/2024.
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Based on staff interviews and records review, the licensee did not report the death of a resident (R1). This posed a potential safety risk to 1 of 3 residents in care
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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.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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