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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003654
Report Date:
12/08/2021
Date Signed:
12/08/2021 03:13:29 PM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
TESSIE'S PLACE LOVING CARE HOME #1
FACILITY NUMBER:
306003654
ADMINISTRATOR:
NOEL GUTIERREZ
FACILITY TYPE:
740
ADDRESS:
27642 ROSEDALE DRIVE
TELEPHONE:
(949) 487-0529
CITY:
SAN JUAN CAPISTRANO
STATE:
CA
ZIP CODE:
92675
CAPACITY:
6
CENSUS:
5
DATE:
12/08/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Noel Gutierrez
TIME COMPLETED:
03:31 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Administrator Noel Gutierrez. Romualdo Amante was present during the visit. LPA explained the reason for the visit. LPA and Administrator toured the facility. Smoke detectors/carbon monoxide detectors tested operational. LPA observed all 5 resident rooms had the required furnishings. All 5 resident bathrooms were clean and operational. All grab bars are secure. The facility is two stories. The second story is for the staff only. There is a gate on the staircase to prevent residents from going upstairs. LPA and Administrator toured the second story. The second story does not house any residents in care. LPA observed the emergency stair chair lift. LPA inspected the kitchen. LPA observed knives and sharp objects are kept secured and inaccessible to residents. LPA observed medications are kept locked in a pantry. LPA observed the facility has a 2 day perishable and 7 day non-perishable food supply on hand. LPA and Administrator toured the garage. The garage kept locked and used for storage. LPA observed extra supplies and food in the garage. LPA and Administrator toured the backyard. No bodies of water observed. LPA observed 4 sheds in the backyard. All of the sheds are used for storage and kept locked. Both exit gates are operational. Facility has a mitigation plan that is pending review. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME:
Luz Adams
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/08/2021
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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