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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003656
Report Date: 08/18/2026
Date Signed: 08/18/2026 03:06:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/11/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260811135915
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:
08/18/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jayson BayronTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff do not ensure facility is free from pests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the investigation, LPA toured the facility and interviewed staff and witness. Regarding the allegation that staff do not ensure facility is free from pests, the investigation revealed the following: Staff and witness confirms the prior presence of ants but states they have since been eliminated. Facility obtained extermination services on 08/11/2026 and provided an invoice for the services. Additionally, LPA viewed a video of the contractor spraying the yard. LPA toured the facility and did not observe any ants during today's visit. Based on interviews conducted and record review, the preponderance of evidence standard has been met, Therefore, the allegation is deemed substantiated. Violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with facility representative and a copy of this report provided along with Appeal Rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
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 2
Control Number 22-AS-20260811135915
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2026
Section Cited
CCR
87303(a)
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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 req is not met as evidenced by:
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Facility provided an invoice for pest control. CLEARED DURING VISIT.
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Based on interviews conducted and record review, Licensee failed to ensure facility was clean and sanitary. Witness and staff state facility had ants throughout the facility which poses a potential health and safety risk to residents in care.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2