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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003654
Report Date: 12/15/2022
Date Signed: 12/15/2022 03:36:56 PM


Document Has Been Signed on 12/15/2022 03:36 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
ORANGE & INLAND A/SC, 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:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mel Amante, Administrator
Noel Gutierrez, Administrator		TIME COMPLETED:
04:00 PM
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On 12/15/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA was greeted and granted entry by Jose Barros, caregiver after explaining the purpose of the visit. Administrator Mel Amante and Noel Gutierrez were notified of the visit by telephone and arrived shortly afterwards to assist with the visit.

LPA accompanied by caregiver toured the physical plant of the facility. There are currently six (6) residents in care, including one resident currently in the hospital. Residents present are observed relaxing in their respective bedrooms or in the common areas and appear clean and well taken care of. Bedrooms are all equipped with the required elements of furnishing. The bathrooms are equipped with grab bars and slip mats. An ample supply of linen is observed. Facility is observed to be clean, sanitary and free of odors in all areas inspected. Sharp instruments are kept secured in a kitchen drawer equipped with a functioning lock. Cleaning supplies are stored under the kitchen sink secured by a padlock. The centrally stored medication is located in a cabinet with a key lock that is observed to be functional. Sound alarms are noted to be present on each route of egress and observed to be functional.

LPA observed a sufficient supply of food and water present. The fire extinguisher present is charged and mounted with a current maintenance tag. Staff members present are adequately cleared and associated in Guardian. Administrator certificate on display is shown to be current.

CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TESSIE'S PLACE LOVING CARE HOME #1
FACILITY NUMBER: 306003654
VISIT DATE: 12/15/2022
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CONTINUED FROM FORM LIC809

LPA and caregiver toured the outside of the facility. Outdoor furniture and a shaded area are present in the backyard for the enjoyment of residents and visitors. The perimeter gates on both sides of the house can easily be opened in case of an evacuation. Plywood board is observed across the route leading out on the right side of the house, but was removed by staff when pointed out. There are no bodies of water on the premises.

The laundry area is located next to one of the bathrooms. Laundry detergent is stored in a locked cabinet equipped with a padlock. However, two bottle of laundry products are observed in an adjacent cabinet which is unsecured. Staff relocated the detergent in the appropriately secured cabinet during the visit.

Based on the observations made during today’s visit, one deficiency are being cited per Title 22 Division 6 of the California Code of Regulations. Two Technical Advisory notes are also being issued during the visit. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/15/2022 03:36 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
ORANGE & INLAND A/SC, 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: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2023
Section Cited

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The California Code of Regulations Section 87705(f) on the Care of Persons with Dementia states: "The following shall be stored inaccessible to residents with dementia: (2) (...) toxic substances such as (...) cleaning supplies(...).
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Licensee will conduct in-service training of facility staff on the secure storage of potentially dangerous items and substances. Licensee will also replace the non-functional magnetic lock of the cabinet under the kitchen sink.
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This requirement is not met as evidenced by: Laundry detergent, were observed to be accessible due to unlocked doors.
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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