Mesa Del Mar Elderly Care Home

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced visit to verify facility closure, and to ensure no clients were receiving care and supervision at the facility. LPA was greeted by Licensee Gary Bergum. Licensee informed LPA that last client's day on site was on July 1, 2026. On today's date, LPA conducted a tour of the physical plant. LPA observed facility in a middle of a remodel. LPA observed items packed in containers and plastic bags. LPA observed no signs of residents or the facility in operation. LPA requested the facility license as it is part of the closure process, and the license was surrendered during the visit. LPA informed the above facility representatives of the licensing procedure for future facility operation if desired. Licensee has decided to permanently close the facility at this time. The Department will proceed with the closure as of July 7, 2026. An exit interview was conducted with staff representative and a copy of the report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 7, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. LPA observed the kitchen is clean and organized. LPA observed sufficient non-perishable food and perishable food at the facility for residents. LPA observed utilities on and operational. LPA observed one resident in the living room and two residents in their rooms. Licensee Gary Bergum lives at the facility and notified LPA of his intention to close the facility. LPA explained to licensee the process of closing including providing a 60 day eviction notice to all residents and/or their responsible parties, informing the Department of when the notices were issued, and a final closure inspection by the Department once the last resident leaves the facility. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Fred Arias for the purpose of a health and safety check. LPA met with Administrator (AD) Cynthia Shayamunda and explained the purpose of the inspection. During the inspection, LPA and AD toured the facility. LPA conducted health and safety checks on residents and confirmed they were doing well and observed no health and safety issues. LPA observed the facility clean and organized and found no health and safety issues. LPA observed utility services operational. LPA observed sufficient resident food. LPA requested and reviewed copies of resident roster, staff roster, and resident files. No deficiencies are being issued at this time. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 17, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to the facility to conduct a plan of correction visit for deficiencies issued on December 2,2025. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Cynthia Shayamunda and discussed the purpose of the visit. LPA toured the facility and observed water temperature was adjusted and measured at 105.4 F, thus clearing deficiency 87303(e)(2). LPA observed physical plant corrections were made including removal of debris in the outdoor walkway, repairing all auditory exit alarms in the facility, and adding a pull string to exit gate, thus clearing deficiency 87303(a). An exit interview was conducted and a copy of this report was discussed and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 17, 2025

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for six non-ambulatory residents. Facility has an approved hospice waiver for four residents and the home currently has four residents, with no residents on hospice. Administrator (AD) Cynthia Shayamunda arrived shortly to assist with the inspection. AD provided updated liability insurance that expires on 4/06/2026. LPA along with staff toured the facility at 9:05 AM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of five resident bedrooms, living room, dining room, and kitchen, two bathrooms and an attached garage. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed bed rails for three resident beds. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 131.5 degrees F and 134 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Four out of five auditory exit alarms were not operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 09/20/2025. Outside grounds were toured. Continued on LIC809-C dated 12/2/2025 Exit Walkway by bedroom 4 is obstructed with old furniture and wood planks. There is shaded outdoor seating for residents. Exit gates are unlocked. Exit gate by bedroom 4 is missing a pull string, making it challenging to open. LPA observed the emergency food and water supply. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of games. LPA reviewed four resident files and two staff files. Resident files contained required documentation including admission agreements, physician reports, and resident appraisals. Three out of four resident files did not include evidence of bed rails orders by a physician. One out of two staff files reviewed contained all required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Dec 2, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: -Faciltiy does not assist resident with dental hygiene

On this day Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA Vanegas was greeted and granted entry to the facility by Administrator (AD) Cynthia Shayamunda after LPA introduced themselves and stated the purpose of the visit. An initial investigation visit was conducted on May 02, 2025. During the visit, LPA Vanegas gathered and reviewed pertinent records pertaining to R1 in regard to the allegations stated above. LPA Vanegas interviewed clients. LPA Vanegas also gathered and reviewed employee files relevant to the allegations being investigated. The investigation in the allegation, facility does not assist resident with dental hygiene, revealed the following. It was alleged that facility staff does not assist resident with dental hygiene. No specific staff members were identified in regard to which one committed the alleged violation. Two of two facility staff were interviewed, and both Staff 1 (S1) and Staff 2 (S2) denied the allegation. CONTINUED ON LIC9099 C Unsubstantiated The Administrator (AD) reported that they have never witnessed hesitation to assist Resident 1 (R1) with dental hygiene or any other activities of daily living. Resident 2 (R2) reported that they get assistance with activities of daily living every day. R2 reports that they get help with grooming, such as shaving, cleaning dentures, and assistance getting changed. R2 reports that they have never witnessed any hesitation of services to residents in care. Resident 1 (R1) reports that staff does not assist them with dental hygiene, and that they do not treat them well, or provide them with medication every day. Based on the evidence gathered the allegation, Facility does not assist resident with dental hygiene, is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with AD Cynthia Shayamunda and a copy of the report provided.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 22-AS-20250422133656

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to the facility. LPA was greeted entry and explained the reason for the visit. LPA met with staff member Florentino Pevralvez. The purpose of today's visit was to conduct a Case Management visit to discuss the present Administrator. Our Regional Office was made aware that the listed Administrator, Mary Jean Catacutan, is no longer the Administrator for the facility. We were made aware Mary Jean Catacutan separated from the facility November 2023. Currently, there is no Administrator working at the facility. Staff member Florentino Pedralvez confirmed the information already known. LPA spoke with Licensee Shelia Bergum over the phone. Licensee stated she is in the process of interviewing Administrator candidates. On this visit, LPA toured the facility and conducted an interview with staff Pedralvez. Based on today's visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with staff representative and a copy of the report was provided along with appeal rights.the state’s words, verbatim · CDSS document, Mar 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Mar 31, 2025

All facilities shall have a qualified and currently certified administrator...the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Licensee to hire a qualified administrator by POC due date. Lincesee to submit Administrator paperwork to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. Facility has 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, 2 car garage and 3 storage sheds in the backyard. Facility is licensed for 6 non-ambulatory residents with a hospice waiver for 4. LPA and staff toured the facility. The Administrator's certificate expires on August 2, 2025. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA observed the living room has a fire place that is screened. LPA observed a wall outlet in the living room that did not have a protective plate over it, the outlet wires are visible. The living room has a TV, 4 reclining chairs, 1 chair and a love seat. LPA observed both bathrooms are clean and operational. Hot water measured 119.6 degrees Fahrenheit in both bathrooms. LPA observed all the resident rooms had the required furnishings. All bedrooms in the facility have an exit and have fire clearance for non-ambulatory residents. LPA observed that in bedrooms 3 and 4 the exit doors were locked and could not be opened by residents in case of an emergency. Staff unlocked the doors during the visit. LPA toured the kitchen. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPA observed the sharp objects are kept locked under the kitchen sink. LPA observed the cleaning supplies are kept locked in the garage. LPA observed medications are kept locked in the hall closet. LPA observed a 3 day emergency supply of food and water stored in the garage. LPA observed liquid cleaner stored outside of it's original container. Purple cleaner (Fabuloso) was stored in 3 Windex bottles and had no additional labels to identify their contents. Smoke/carbon monoxide detectors tested operational. LPA and staff toured the backyard. Both exit gates on each side of the house are operational. LPA inspected all 3 storage sheds. All 3 sheds are kept locked. LPA observed old furniture and supplies stored in the sheds. No bodies of water observed in the backyard. There is a table with an umbrella and chairs to sit outside. No obstacles or hazards observed in the backyard. LPA reviewed 6 resident records and medications. No discrepancies observed. LPA reviewed 2 staff files. Both staff members are background cleared and associated to the facility. Both staff have all the required training and no discrepancies observed in their files. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809Ds. Immediate civil penalty is being assessed due to fire safety deficiencies. See LIC421IM. An exit interview was conducted and copies of this report, deficiency pages, civil penalty assessment, appeal rights, and cited regulations were provided to the facility representative.the state’s words, verbatim · CDSS document, Feb 11, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Unlawful eviction. Incomplete documents.

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 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.the state’s words, verbatim · CDSS document, Jul 10, 2024 · control 22-AS-20240701094019

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(c) · Plan of correction due date: Jul 11, 2024

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. 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.the state’s words, verbatim · CDSS document, Jul 10, 2024

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87507(c) · Plan of correction due date: Jul 11, 2024

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. 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.the state’s words, verbatim · CDSS document, Jul 10, 2024

Plan of correction: 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.

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

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 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.the state’s words, verbatim · CDSS document, May 7, 2024 · control 22-AS-20240501093702