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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003656
Report Date: 07/09/2026
Date Signed: 07/13/2026 07:08:51 AM

Document Has Been Signed on 07/13/2026 07:08 AM - 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/
DIRECTOR:		ROMUALDO AMANTEFACILITY TYPE:
740
ADDRESS:26551 ROYALE DRIVETELEPHONE:
(949) 481-0912
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 4DATE:
07/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:50 AM
MET WITH:Brian and Jayson BayronTIME VISIT/
INSPECTION COMPLETED:
12:17 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Tessie's PL #3. The purpose of today’s visit was to conduct the required annual inspection. LPA was allowed entry into the home and met with Caregiver Brian Bayron. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 5 residents and the home currently has 4 residents of which 2 are on hospice care.

LPA Lyman along with Caregiver Jayson Bayron toured the facility at 8:21 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 4 resident bedrooms, 1 resident bathroom, living room, dining room, and kitchen as well as a staff room and 2 shared hall bathrooms. At 8:25 AM, LPA observed unsecured Comet cleaner in the common restroom. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed 1 resident with full bed rails and 2 residents with half rails. LPA observed the bed for Resident 3 (R3) is blocking the exit. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 96.2 and 104.7 degrees F in tested restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. At 8:45 AM, LPA inspected the kitchen. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed three burners on the stove top are inoperable and staff is using a lighter to start the burners. LPA observed multiple items of spoiled food including zucchini, onion and fruit. Knives are unsecured in a kitchen drawer. LPA observed unsecured pre-poured medications in an unlocked kitchen cabinet. Smoke detectors tested operational during today's visit as well as the Carbon Monoxide detector. Fire extinguisher is charged. At 9:00 AM, LPA observed the exit gate on north side of property has a concrete block and a piece of wood blocking the gate making it inaccessible. The other exit gate is unlocked and self latching. CONTINUED ON LIC 809C DATED 07/09/2026

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2026
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 10
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 10
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
VISIT DATE: 07/09/2026
NARRATIVE
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There is a drained pool secured with a fence in the backyard. LPA observed multiple piles of debris throughout the yard including wood pieces and old furniture. LPA observed the facility does not have emergency food or water on-site. LPA observed unsecured bleach and floor cleaner in the laundry room. At 9:15 AM, LPA observed four resident files and three staff files. Three out of four residents do not have a current physician report on file. Three out of three residents do not have a written physician order for bed rails. Two out of two staff files do not have proof of required annual training. One out of three personnel files are not present at the facility. At 10:30 AM, LPA observed medication storage and administration. Medication is stored in a locked cabinet. Facility is not documenting PRN medication administration.

Licensee has been asked to submit an updated LIC 308 and an updated LIC 500 as well as a copy of the Administrator's Certificate by close of business 07/13/2026.

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 at time of visit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 07/13/2026 07:08 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/09/2026 at 10:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed the exit gate has concrete and wood propped against it making the gate inaccessible as well as R3's bed is blocking the exit in the resident room which poses an immediate health, safety or personal rights risk to persons in care. CIVIL PENALTY ASSESSED
POC Due Date: 07/10/2026
Plan of Correction
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2
3
4
Licensee to remove items blocking exits and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 07/13/2026 07:08 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/09/2026 at 10:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured knives and cleaning supplies which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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2
3
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Licensee to secure noted items and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured pre-poured medications in an unlocked kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee to secure noted items and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 07/13/2026 07:08 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/09/2026 at 10:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed facility is pre-pouring medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee to discontinue pre-pouring medications and forward a statement attesting to discontinuing the practice to LPA by POC due date.
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

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. Licensee is not documenting PRN administration which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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2
3
4
Licensee to provide training to staff regarding PRN medication administration and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 07/13/2026 07:08 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/09/2026 at 10:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed debris throughout the backyard including wood pieces and old furniture and three burners on cook top are inoperable which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2026
Plan of Correction
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2
3
4
Licensee to clean debris in yard as well as repair/ replace burners on cook top and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in three out of three faucets with water temperature between 96.2 and 104.7 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2026
Plan of Correction
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2
3
4
Licensee to adjust water temperature and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 07/13/2026 07:08 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/09/2026 at 10:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(e)(1)(A)
Personal Accommodations and Services
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (1) Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices. (A) Heating devices shall have protective mechanisms or other measures to prevent access to the device, or to make it inoperable when not in use, in order to reduce the risk of burns or fire.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in. Facility does not have protective mechanisms for the cook top knobs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2026
Plan of Correction
1
2
3
4
Licensee to obtain protective mechanisms for cook top and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three staff files not present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2026
Plan of Correction
1
2
3
4
Please ensure Staff 3's file is present at the facility and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 07/13/2026 07:08 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/09/2026 at 10:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in three out of three staff without required annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2026
Plan of Correction
1
2
3
4
Licensee to conduct training ad forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed multiple items of spoiled food in the refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2026
Plan of Correction
1
2
3
4
Licensee to audit refrigerator for additional items out of date or spoiled and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 07/13/2026 07:08 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/09/2026 at 10:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in three out of three residents with bed rails and no physician order which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2026
Plan of Correction
1
2
3
4
Licensee to obtain written physician orders for bed rails and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
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