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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003655
Report Date: 01/08/2025
Date Signed: 01/08/2025 12:34:28 PM

Document Has Been Signed on 01/08/2025 12:34 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TESSIE'S PLACE LOVING CARE HOME #2FACILITY NUMBER:
306003655
ADMINISTRATOR/
DIRECTOR:		ROMUALDO AMANTEFACILITY TYPE:
740
ADDRESS:27021 MISSION HILLS DR.TELEPHONE:
(949) 443-1496
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:02 AM
MET WITH:Romualdo AmanteTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the annual required inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Romualdo Amante and explained the reason for the visit. Administrator Mel Amante's Administrator's certificate expires on March 26, 2025. Facility is licensed for 6 non-ambulatory residents, hospice waiver for 2 residents. Facility has 5 bedrooms, 3 bathrooms, living room, kitchen, dining room, storage room, activity room/family room and an attached 3 car garage that is used for storage and kept locked. LPA and the Administrator toured the facility. LPA observed the See Something, Say Something poster posted in the main entrance of the facility. .LPA observed all 3 bathrooms are clean and operational. Hot water measured 115.1 degrees Fahrenheit in all 3 bathrooms. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. Medications are kept locked in a kitchen cabinet. Knives and sharp objects are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the kitchen sink. The storage room is located next to the kitchen and is a pass through to the garage. The storage rooms has an exit door to the backyard. The storage room has boxes and furniture stored in such a way that access to the garage and exit door are blocked. It is not possible to walk through the storage room. LPA observed clean linens stored in the hall closet. LPA observed the 5 resident rooms are clean and have all the required furnishings. LPA observed 3 out of the 5 resident rooms did not have a smoke detector. The smoke detectors in the two other resident rooms and throughout the facility tested operational. The carbon monoxide detector in the entry way of the facility tested operational. LPA toured the backyard. No bodies of water observed. LPA observed both exit gates are operational. LPA observed a shaded patio with seating to sit outside. LPA reviewed 2 staff records, 6 resident records and medications. LPA observed that 3 out of 6 residents are on hospice and the facility has a hospice waiver for 2, facility is operating beyond the limits of the license. No other discrepancies noted. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. Civil penalty assessed on today's date. (SEE LIC 421IM) for citation (CCR) 87203 Fire Safety. An exit interview was conducted and a copy of the report provided along with appeal rights.
Sheila SantosTELEPHONE: (714) 334-2062
Joseph AlejandreTELEPHONE: 714-705-6018
DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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Document Has Been Signed on 01/08/2025 12:34 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 COUNTY RO, 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: 01/08/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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 met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA observed there are no smoke detectors in 3 out of 5 resident bedrooms, which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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Licensee agrees to install smoke detectors in the 3 resident rooms and to always have working smoke detectors in the facility as required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sheila SantosTELEPHONE: (714) 334-2062
Joseph AlejandreTELEPHONE: 714-705-6018

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/08/2025 12:34 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 COUNTY RO, 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: 01/08/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents, Facility is 1 resident above their current hospice waiver which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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Licensee agrees to request a hospice waiver increase and to submit a statement showing they have read and understand and agree to comply with CCR 87204 and CCR 87633.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sheila SantosTELEPHONE: (714) 334-2062
Joseph AlejandreTELEPHONE: 714-705-6018

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025

LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/08/2025 12:34 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 COUNTY RO, 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: 01/08/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, It is not possible to walk through the storage room because the amount of boxes and furniture in the room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Licensee agrees to clear the room of boxes and furniture so it is possible to walk to each door in the room without hinderance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sheila SantosTELEPHONE: (714) 334-2062
Joseph AlejandreTELEPHONE: 714-705-6018

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025

LIC809 (FAS) - (06/04)
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