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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003656
Report Date: 07/26/2022
Date Signed: 07/26/2022 04:45:15 PM


Document Has Been Signed on 07/26/2022 04:45 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
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: DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Romualdo AmanteTIME COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for Covid-19 and granted entry. LPA met with Administrator Romualdo Amante. LPA explained the reason for the visit. LPA and Administrator toured the facility. The facility has 5 bedrooms, 3 bathrooms, living room, family room, kitchen and a 3 car garage. LPA observed all resident rooms had the required furnishings. LPA observed a 2 day perishable and a 7 non-perishable food supply on hand in the kitchen. The garage is kept secured and off limits to residents. LPA and Administrator toured the backyard. There is a pool that is empty in the backyard. The pool gates are kept locked. LPA observed the passage on each side of the house leading to the exit gates are clear. Both exit gates are operational. The hot water measured 110.0 degrees Fahrenheit. Smoke detectors/carbon monoxide detectors tested operational. LPA observed the medication is kept locked in a kitchen cabinet. No obstacles or hazards observed in the facility. No deficiencies are being cited as a result of this visit. LPA consulted with the Administrator concerning continued Covid-19 mitigation and reporting requirements. An exit interview was conducted and a copy of the report
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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