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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004335
Report Date: 12/17/2024
Date Signed: 12/17/2024 10:49:53 AM

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
12/16/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20241216083237
FACILITY NAME:TALEGA TERRACEFACILITY NUMBER:
306004335
ADMINISTRATOR:JAYALAKSH PICHIKAFACILITY TYPE:
740
ADDRESS:24 VIA ANDAREMOSTELEPHONE:
(949) 545-7574
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 5DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Jaya PichikaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility staff are not ensuring that trash is removed from the property.
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 visit, LPA toured the facility and interviewed Administrator. Regarding the allegation that facility staff are not ensuring that trash is removed from the property, the investigation revealed the following: Upon arrival to the facility, LPA observed a broken book shelf and some miscellaneous debris outside the facility. Administrator indicated there was a scheduled pick up for the items on 12/20/2024. LPA observed a van in the driveway. Administrator stated the facility has not used the van for residents in approximately 5 years and is simply parked in the driveway. LPA observed some boxes inside the van. Based on interview conducted and observation, the preponderance of evidence standard has been met, therefore above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report was left at the facility along with appeal rights.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 22-AS-20241216083237
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: TALEGA TERRACE
FACILITY NUMBER: 306004335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2024
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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Licensee to remove noted items and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure facility is safe and sanitary. LPA observed a broken bookshelf and miscellaneous debris outside the facility. This 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2