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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003655
Report Date: 11/29/2021
Date Signed: 11/29/2021 01:51:08 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/24/2021 and conducted by Evaluator Joseph Alejandre
COMPLAINT CONTROL NUMBER: 22-AS-20211124103852
FACILITY NAME:TESSIE'S PLACE LOVING CARE HOME #2FACILITY NUMBER:
306003655
ADMINISTRATOR:ROMUALDO AMANTEFACILITY TYPE:
740
ADDRESS:27021 MISSION HILLS DR.TELEPHONE:
(949) 443-1496
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 5DATE:
11/29/2021
UNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Romualdo AmanteTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility did not maintain liability insurance.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Joseph Alejandre and Jerome Haley made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPAs were greeted and granted entry by staff. LPAs explained the reason for the visit. The investigation into the allegation, facility did not maintain liability insurance, revealed the following; The facility had the required liability insurance from 8/24/2019 to 8/24/2020. The email reviewed showed the insurance police expired on 8/24/2020. Administrator verified the policy was allowed to lapse and at this time the facility does not have liability insurance. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with the Administrator and a copy of this report provided along with the citation and Appeal Rights (LIC 9058 01/16).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20211124103852
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 #2
FACILITY NUMBER: 306003655
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
Section Cited
HSC
1569.605
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On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
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LIcensee agrees to purchase insurance for the facility as required by the Health & Safety code and to provide proof of insurance to the Agency by 12/14/2021.
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This requirement is not being met as evidenced by, facility does not have a record of insurance coverage and Administrator reported that the coverage has expired. 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: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC9099 (FAS) - (06/04)
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