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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003656
Report Date: 07/17/2026
Date Signed: 07/17/2026 02:02:19 PM

Document Has Been Signed on 07/17/2026 02:02 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/
DIRECTOR:		ROMUALDO AMANTEFACILITY TYPE:
740
ADDRESS:26551 ROYALE DRIVETELEPHONE:
(949) 481-0912
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 5DATE:
07/17/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Jayson BayronTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 07/09/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. LPA Lyman spoke with Administrator Mel Amante via telephone.

*Deficiency cited under Title 22 Regulation 87309(a) pertaining to Storage Spaces has NOT been cleared. During today's visit, LPA observed the unsecured the cleaning supplies noted in the LIC 809 were still unsecured. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ASSESSED

*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has NOT been cleared. During today's visit, medications are unsecured in an unlocked cabinet. Licensee has NOT complied with the POC. CIVIL PENALTY ASSESSED.

*Deficiency cited under Title 22 Regulation 87203 pertaining to Fire Safety has been cleared. During today's visit, the exit gate and the exit door in resident bedroom is not blocked. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87465(h)(5) pertaining to Pre-Poured Medication has been cleared. During today's visit, pre-pouring has been discontinued. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87465(c)(3) pertaining to PRN Documentation has been cleared. During today's visit, facility is documenting PRN medication administration. Licensee has complied with the POC

CONTINUED ON LIC 809C DATED 07/17/2026.



NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2026
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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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)
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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: 07/17/2026
NARRATIVE
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During today's visit, LPA observed a room built in the garage that is not on facility approved floor plan. Additionally, LPA observed the dining room on floor plan is being used as a staff room and the adjoining patio has a wood wall put up where there should be an exit.









Based on the observations made during today's visit, Deficiencies are being 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: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/17/2026 02:02 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/17/2026 at 01:23 PM
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: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2026
Section Cited
CCR
87202(a)

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...This req is not met as evidenced by:
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Licensee to submit LIC 200 with current floor plan and updated floor plan to LPA by POC due date.
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Based on observation, Licensee failed to maintain fire clearance. Licensee built a room in the garage, put up a wall in the patio and is using the designated dining room as a staff room, none of which are on approved floor plan. These items negate approved fire clearance which poses an immediate health and safety risk. CIVIL PENALTY ASSESSED.
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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
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