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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003656
Report Date: 07/29/2021
Date Signed: 07/29/2021 05:57:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 #3FACILITY NUMBER:
306003656
ADMINISTRATOR:ROMUALDO AMANTEFACILITY TYPE:
740
ADDRESS:26551 ROYALE DRIVETELEPHONE:
(949) 481-0912
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 5DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Romualdo AmanteTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry. LPA toured the facility with Administrator Romualdo Amante. Romualdo Amante administrator's certificate expires on 3/26/2023. LPA and Administrator toured the outside of the facility. LPA observed debris including wood logs, plastic bottles, cans and boxes on the side of the house. LPA observed the pool in the backyard is empty. There is a fence surrounding the pool but it is not secured. LPA observed there was an empty dog house in the backyard surrounded by a small fence. LPA toured the inside of the facility. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand. Smoke detectors tested operational. The garage is used for storage. LPA observed locked storage cabinets in the garage that are used to store supplies. LPA observed all the resident rooms have the required furnishings.
Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview conducted and a copy of the appeal rights were given to the Administrator at time of visit. A copy of the report was provided to the Administrator.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 #3
FACILITY NUMBER: 306003656
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(e)
Swimming pools and other bodies of water shall be fenced and in compliance with State and local building codes.

This requirement is not met as evidenced by: LPA observed the pool fence gate closest to the east side property fence is not secured and can be openned by moving the latch. This leaves the pool accessible to persons in care.
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out of 2 pool gates which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2021
Plan of Correction
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Licensee states the pool fence will be made secure and inaccessible to persons in care by locking the pool gate with a new lock.
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.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 #3
FACILITY NUMBER: 306003656
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
All outdoor and indoor passageways, stairways, incines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction

This requirement is not met as evidenced by: LPA observed debris, bottles, cans, boxes and logs on the side of the house on the pathway to the exit gate.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 pathways to the exit gates which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2021
Plan of Correction
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Licensee states that the pathways leading to each exit gate will be cleared and not contain any obstacles, hazards or debris, including, bottles, cans, boxes and wood logs or pieces.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3