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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003655
Report Date:
12/28/2021
Date Signed:
12/28/2021 01:53:24 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 #2
FACILITY NUMBER:
306003655
ADMINISTRATOR:
ROMUALDO AMANTE
FACILITY TYPE:
740
ADDRESS:
27021 MISSION HILLS DR.
TELEPHONE:
(949) 443-1496
CITY:
SAN JUAN CAPISTRANO
STATE:
CA
ZIP CODE:
92675
CAPACITY:
6
CENSUS:
4
DATE:
12/28/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:31 AM
MET WITH:
Romualdo Amante
TIME COMPLETED:
02:05 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. LPA explained the reason for the visit. LPA met with Administrator Romualdo Amante. Romualdo Amante's Administrator's Certificate expires on 3/26/2023. LPA and Administrator toured the facility. LPA observed all resident bedrooms had the required furnishings. LPA observed all 3 bathrooms were clean and operational. Hot water temperature measured 119.3 degrees Fahrenheit. LPA observed the garage is used for storage and kept locked. LPA observed the fireplace in the living room and the fireplace in the TV room are both screened. LPA and Administrator toured the backyard. There is a patio area with seating and a gazebo. Both exit gates on each side of the house are operational. LPA observed there is a 2 day supply of perishable food and a 7 day supply of non-perishable food on hand in the kitchen. The kitchen is cleaned and organized. LPA observed the knives are kept locked in a drawer. Medication is kept locked in a pantry. All fire extinguishers are fully charged. Smoke detectors and carbon monoxide detector tested operational. Facility has a mitigation plan that is pending review. No deficiencies are being cited as a result of this visit.
SUPERVISOR'S NAME:
Luz Adams
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2021
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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