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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003654
Report Date: 06/24/2022
Date Signed: 06/24/2022 04:58:32 PM


Document Has Been Signed on 06/24/2022 04:58 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:TESSIE'S PLACE LOVING CARE HOME #1FACILITY NUMBER:
306003654
ADMINISTRATOR:NOEL GUTIERREZFACILITY TYPE:
740
ADDRESS:27642 ROSEDALE DRIVETELEPHONE:
(949) 487-0529
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 6DATE:
06/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Noel Gutierrez, Romualdo AmanteTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA met with Administrator Noel Gutierrez and Romualdo Amante. On 6/7/2022 the Agency (CCL) received a report that Resident 1 (R1) left the facility unassisted on 5/29/2022. R1 left the facility unassisted and was gone 4 to 5 hours. R1 left the facility sometime between 4 and 5pm when visitors left the facility and the door was opened. After the visitors had left staff discovered R1 was not at the facility. Staff could not find R1 and contacted the Administrator and the police. The facility called the police and were informed R1 was at the hospital to be evaluated. The police were contacted by a concerned neighbor that an elderly person appeared to be lost. The police found R1 and took them to the hospital to be checked. The facility contacted the responsible party. The facility Administrator returned R1 to the facility when they were released from the hospital around 9 pm. R1 is at the facility and no further issues reported. The facility does have a front door alarm and is doing regular checks on all the residents. Based on the information gathered through interviews and a review of the incident reports, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided to the Administrator.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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 06/24/2022 04:58 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: TESSIE'S PLACE LOVING CARE HOME #1
FACILITY NUMBER: 306003654

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2022
Section Cited

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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Based on interviews and a review of incident reports, Licensee failed to ensure care and supervision was provided to R1. R1 eloped out of the facility and was found by the police and taken to the hospital. This poses an immediate health and safety risk to 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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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