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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003655
Report Date: 01/13/2023
Date Signed: 01/13/2023 12:22:23 PM


Document Has Been Signed on 01/13/2023 12:22 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 #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: 4DATE:
01/13/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mel Amante, AdministratorTIME COMPLETED:
12:30 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unnanounced visit to the facility for the purpose of following up on the plan of corrections for deficiencies observed during the annual visit conducted on 12/15/2022. LPA was greeted and granted entry by caregiving staff and explained the purpose of the visit. Administrator Mel Amante, arrived shortly after wards to assist with the visit.

During the annual inspection visit on 12/15/2022, LPA observed padlocks installed and locked on both perimeter exit gates. A type A deficiency was cited and immediate civil penalty assessed. Licensee removed padlocks during the conducted inspection visit after being informed of the requirements for the approval of locked gates.

As part of the present visit, LPA observed that the padlock have effectively been removed at this time.

During the annual inspection visit on 12/15/2022, LPA observed laundry detergent, cleaning supplies and staff personal medication left accessible due to unlocked doors or a non-functional cabinet lock. A type B deficiency was cited.

As part of the present visit, LPA was able to confirm that all potentially dangerous items were made inaccessible to individuals in care. In-service training of facility staff on the secure storage of potentially dangerous items and substances has been conducted and the non-functional magnetic lock of the cabinet under the kitchen sink has been replaced.

The plan of corrections for both deficiencies was cleared during today's visit. An exit interview was conducted and a copy of this report along with two plan of corrections clearance letters were printed and left with facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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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