306003655-12-15-2022-22-AS-KSGH-CM5SQN-20221215130501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003655
Report Date: 12/15/2022
Date Signed: 12/15/2022 01:05:12 PM

Document Has Been Signed on 12/15/2022 01:05 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 #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:	12/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mel Amante, Administrator		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 Manny Balana, caregiver after explaining the purpose of the visit. Administrator Mel Amante was 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 four (4) residents in care. Residents present are observed relaxing in their respective bedrooms or in the common areas with visitors and appear clean and well taken care of. Bedrooms are all equipped with the required elements of furnishing. Resident R-1's bed is observed to be equipped with half rails for postural support. Resident is confirmed to be receiving hospice care. The two 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. The magnetic lock for one of the two doors is observed to be non-functional during the visit. The centrally stored medication is located in a cabinet with a functional magnetic lock that is observed to be functional. LPA observed a sufficient supply of food and water present. The fire extinguisher present is charged and mounted. The maintenance tag is however outdated with the last maintenance performed in October of 2019. The fire extinguisher was replaced during the inspection. 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 Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (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)

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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 #2	FACILITY NUMBER: 306003655
	VISIT DATE: 12/15/2022

NARRATIVE

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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 are shown to be equipped with padlocks, one of which is observed to be locked during the visit. Administrator states that the facility occasionally locked these due to residents wandering. More recently, a concern regarding break-ins in the neighborhood has prompted facility staff to lock the gates at night. LPA provided consultation on the applicable regulations for the locking of gates. Padlocks were removed during the duration of the visit. There are no bodies of water on the premises.

The laundry area is located in the attached garage, where staff lockers are also located. Laundry detergents are stored in a locked cabinet equipped with a padlock. However, a box containing spray paint as well as a plastic bag containing laundry detergent and fabric softener for use by staff members are observed to be left out.

The staff bedroom door is observed to be left unlocked by staff present. Medications are observed in the room and are accessible to individuals in care.

Based on the observations made during today’s visit, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Violation advisory as well as 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 Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (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)

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Document Has Been Signed on 12/15/2022 01:05 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 #2	FACILITY NUMBER: 306003655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

The California Code of Regulations Section 87203 regarding Fire Safety "All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.:" This requirement is not being met as evidenced by: Facilty has installed padlocks on the perimeter gates located on both sides of the physical plant. Based on observation, the licensee did not comply with the section cited above. LPAs observed both exit gates are secured. One gate is secured with a padlock and one gate is secured. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED. Licensee removed lock during visit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews and record review), the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2022
	Plan of Correction
1 2 3 4	Licensee removed padlocks during the conducted inspection visit. Licensee informed of the requirements for the approval of locked gates.

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 Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (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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Document Has Been Signed on 12/15/2022 01:05 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 #2	FACILITY NUMBER: 306003655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)

The California Code of Regulations Section 87705(f) on theCare of Persons with Dementia states: "The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Laundry detergent, cleaning supplies and staff personal medication were observed to be accessible due to unlocked doors or a non-functional cabinet lock.
	Deficient Practice Statement
1 2 3 4	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.
	POC Due Date: 01/15/2023
	Plan of Correction
1 2 3 4	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.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (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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