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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003655
Report Date: 05/15/2026
Date Signed: 05/15/2026 03:57:51 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
02/13/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250213114436
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:
05/15/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Medalla EdwardsTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained unexplained scratches while in care
Staff do not follow resident's care plan
Staff leave resident in wet diapers for extended periods of time
Resident developed a pressure injury due to staff neglect
Staff do not provide a comfortable environment for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with facility staff and explained the reason for the visit.

The investigation into the allegation, resident sustained unexplained scratches revealed the following. It was reported that Resident 1 (R1) had four nail marks on the top of their right hand and scratches on their forearm which were noticed by a witness on February 10, 2025. It was reported the scratches were caused by staff members. R1 moved into the facility on January 8, 2025 and moved out of the facility on February 25, 2025. R1 has been diagnosed with Parkinson's disease. The Administrator reported that staff had informed him of the scratches and staff did not know what caused the scratches. Witness 1 (W1) reported that R1 told them staff caused the scratches. LPA attempted to interview R1 but they were not oriented to the time or their location. R1 did not respond to any questions from the LPA. 4 out of 4 staff interviewed who assist R1 denied the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
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 4
Control Number 22-AS-20250213114436
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/15/2026
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The Administrator reported they reported the issue to R1's responsible party. W1 reported that they never witnessed any abuse by the staff toward any of the residents. The cause of the scratches on R1 is unknown.
LPA interviewed R1's physical therapist who reported they have never witnessed any type of abuse at the facility. 2 out of 5 residents interviewed reported they have never witnessed or experienced any abuse from staff. 3 out of 5 residents did not respond to LPAs questions and could not be interviewed. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff do not follow resident's care plan, revealed the following. It was reported that R1 was not assisted with their incontinence and not changed as often as listed in their doctors orders and R1 is to be kept upright for 10 to 15 minutes after taking medication and drinking liquids. The Administrator reported that the care plan is based off of doctor's orders and no such orders were provided. A review of records shows the only doctor's orders provided are for R1 to be rotated every 2 hours to assist with blood flow, prevention of pressure injuries and to check every 2 hours for incontinence to ensure proper hygiene to minimize pressure injuries. The Administrator reported that R1's responsible party asked them to keep R1 upright after taking medications and drinking liquids for 10 to 15 minutes but they never provided a doctor's order so they didn't do it. 4 out of 4 staff reported that R1 was checked every hour and changed at least 3 times a day and whenever required to ensure they were clean and to minimize any skin breakdown. R1's responsible party reported they had additional doctor's orders but they were not provided to the LPA and they could not explain why they weren't provided to the facility. The Administrator reported they follow all doctor's orders and attempted to work with R1's responsible party but they did not receive a response. R1's responsible party could not explain why they didn't respond to the Administrator. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff leave resident in wet diapers for extended periods of time, revealed the following. It was reported that R1 was left in soiled briefs for extended periods of time. No specific details were provided as to the date or time when this occurred.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20250213114436
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/15/2026
NARRATIVE
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R1's responsible party reported that they have never witnessed R1 in soiled briefs and did not have any first hand knowledge of R1 ever being left in soiled briefs. R1's physical therapist reported they have never witnessed R1 being left in soiled briefs and thought the staff were very attentive to all the residents. The Administrator reported that all staff are trained to check each resident at least every 2 hours and to check R1 every hour because of their condition. 4 out of 4 staff interviewed denied the allegation and reported that R1 is changed checked and changed regularly and has never been left in soiled briefs. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, resident developed a pressure injury due to staff neglect, revealed the following. It was reported that because the facility staff did not clean R1 regularly, did not rotate R1 regularly and did not change R1 regularly, R1 developed a pressure injury while residing at the facility. The Administrator reported that R1 moved in with a stage 1 pressure injury and had home health visits starting right after they moved in. Staff 1 reported they saw R1's stage 1 pressure injury on the day they moved in they were told to keep R1 clean and dry and to rotate R1 every 2 hours. 4 out of 4 staff reported they kept R1 clean and rotated them every 2 hours. R1's physician report dated July 1, 2024 which was provided to the facility when R1 moved in, shows R1 has a stage 1 pressure injury on their coccyx, is prone to fungal infections and pressure injuries. The Administrator reported that R1 had home health visits twice a week for their pressure injury. R1's responsible party verified this information. LPA contacted the Home Health company to interview the 2 home health nurses who provided care to R1 but never received a response. 4 out of 4 staff reported they followed the instructions from the nurses and R1 was properly cared for. The Administrator reported that R1 moved out of the facility on February 25, 2025 prior to their wound completely healing and reported that wound was improving. R1's responsible party verified this information. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20250213114436
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/15/2026
NARRATIVE
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The investigation into the allegation, staff do not provide a comfortable environment for resident, revealed the following. It was reported that R1 was not provided a comfortable environment. No details were provided regarding this allegation. LPA measured the temperature of the facility and it was 75.0 degrees Fahrenheit. LPA did not observe any obstacles or hazards or any strong odors in the facility. LPA interviewed 2 out 5 residents who reported they were comfortable at the facility and had no issues. R1 did not respond to any of the LPA's questions so they were not interviewed. 3 out of 5 residents did not respond to LPA's questions so they were not interviewed. LPA observed R1's bed had a mattress with a foam pad and clean linens and R1 was clean, dressed and groomed. The Administrator reported that no one has complained to them about an uncomfortable environment. 4 out of 4 staff reported that none of the residents or visitors has reported anything about an uncomfortable environment. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with facility staff and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4