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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801158
Report Date: 07/20/2022
Date Signed: 07/20/2022 02:36:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210625101437
FACILITY NAME:MESA CAREFACILITY NUMBER:
425801158
ADMINISTRATOR:VALENTYNA POLUNETSFACILITY TYPE:
740
ADDRESS:2424 CALLE SORIATELEPHONE:
(805) 965-2428
CITY:SANTA BARBARASTATE: CAZIP CODE:
93109
CAPACITY:6CENSUS: 6DATE:
07/20/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Alex Poluntes, LicenseeTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility exceeds approved capacity.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted subsequent visit to deliver final findings. LPA met with Alex Poluntes, Licensee and explained the purpose of the visit.
On 6/29/21 Licensing Program Analysts Toan Luong and Darlene Chavez conducted an initial 10 day complaint inspection at Mesa Care and met with Administrator Valentina Polunets. LPAs requested documents pertinent to the investigation. LPAs interviewed administrator and 4 residents. LPA Luong conducted interviews with witness, residents, and staff on 6/24/21 through 6/29/21, 8/24/21, 8/25/21, and 10/5/21. LPA reviewed facility documents.

On the allegation: Facility exceeds approved capacity. It was alleged that the facility was at maximum capacity of 6 and had a 7th resident around 6/21/2021. LPA Luong’s interview revealed that there was an individual age 96, Resident 7 (R7) was at the facility between 6/21/2021 to 6/22/2021. Staff interviews confirmed an individual was at the facility during that time but only reported as a day visit.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
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 5
Control Number 29-AS-20210625101437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MESA CARE
FACILITY NUMBER: 425801158
VISIT DATE: 07/20/2022
NARRATIVE
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LPA Luong requested the contact information of R7 and their parties. Administrator informed LPA that it was a day visit, and R7 was performing a trial period with their family to see if the facility was an appropriate fit for R7. One resident was expected to move out at the end of the month, and the licensee wanted to ensure the vacancy would be filled. The licensee receives numerous requests for a trial and did not have R7’s contact information. The facility did not have a visitor’s log upon LPA’s request. LPA informed the facility this was a requirement as a result of the Coronavirus Disease and should have been implemented as part of the facility’s mitigation plan. Other interviews reported that R7 had been at the facility for several days. Among the other interviews includes a credible witness who was present at the facility and witnessed R7 sitting at the table by self with no other visitors. Credible witness also reported that staff informed the credible witness that R7 was at the facility for several days. Although it could not be determined how long R7 stayed, there is sufficient evidence based off interviews that R7 was at the facility without their representative. Without their representative the facility would have been required to provide care and supervision to R7 for the day and therefore exceeded the license capacity of 6. Therefore the allegation Facility exceeds approved capacity is substantiated.

LPA conducted exit interview, deficiency issued on 9099-D, and provided a copy of this report along with appeal rights to the facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20210625101437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MESA CARE
FACILITY NUMBER: 425801158
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited
CCR
87158(a)
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87158(a) Capacity. A license shall be issued for a specific capacity which shall be the maximum number of residents which can be provided care at any given time…

This requirement was not met as evidence by:
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Licensees to provide a written statement of understanding and acknowledgement of regulation 87158. Licensee agreess to not exceed the capacity. Licensee understands prospective residents may not be provided care and supervision by staff.
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Based on interviews and eyewitness, the facility had a 7th resident at the facility without their representative and staff would have needed to provide care and supervision which poses an immediate health and safety risk to persons 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210625101437

FACILITY NAME:MESA CAREFACILITY NUMBER:
425801158
ADMINISTRATOR:VALENTYNA POLUNETSFACILITY TYPE:
740
ADDRESS:2424 CALLE SORIATELEPHONE:
(805) 965-2428
CITY:SANTA BARBARASTATE: CAZIP CODE:
93109
CAPACITY:6CENSUS: 6DATE:
07/20/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Alex Polunets, LicenseeTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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3
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9
Facility staff verbally abuse resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted subsequent visit to deliver final findings. LPA met with Alex Poluntes and explained the purpose of the visit.

On 6/29/21 Licensing Program Analysts Toan Luong and Darlene Chavez conducted an initial 10 day complaint inspection at Mesa Care and met with Administrator Valentina Polunets. LPAs and requested documents pertinent to the investigation. LPAs interviewed administrator and 4 residents. LPA Luong conducted interviews with witness, residents, and staff on 6/24/21 through 6/29/21, 8/24/21, 8/25/21, and 10/5/21. LPA Luong reviewed facility documents.

On the allegation: Facility staff verbally abuse resident. It was alleged that staff screamed and yelled at a resident. LPA interviewed residents, staff, and witnesses. LPA’s interviews revealed a witness outside of the facility heard yelling. LPA’s interviews reveal that Resident #2 (R2) is diagnosed with dementia. R2’s responsible party, Witness 4 (W4), described R2 as “malcontent” and “never happy.” Cont on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20210625101437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MESA CARE
FACILITY NUMBER: 425801158
VISIT DATE: 07/20/2022
NARRATIVE
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R2 was also described as having a history being “nasty” and complained about everything. R2 also has arthritis and had undergone a medication change. During the medication change, R2 became aggressive and would scream and pound on the walls. There was insufficient evidence to prove the allegation facility staff verbally abused resident. Therefore the allegation is deemed unsubstantiated at this time. However, LPA recommends that personal rights training be provided to all staff as a best practice.

Exit interview conducted and a copy of this report will be emailed to Administrator/Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5