306005907-6-16-2026-22-AS-LMOA-DVK2W6-20260630174500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005907
Report Date: 06/16/2026
Date Signed: 06/16/2026 04:46:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
09/07/2021 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210907113019

FACILITY NAME:	TESSA'S PLACE 1		FACILITY NUMBER:	306005907
ADMINISTRATOR:	AVENDANO, ELEONOR		FACILITY TYPE:	740
ADDRESS:	26075 ARCADA DRIVE		TELEPHONE:	(949) 331-3822
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	06/16/2026
		UNANNOUNCED	TIME BEGAN:	03:49 PM
MET WITH:	Mark Cruz- Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.
Staff mismanaged resident's medication.
Staff did not inform resident's authorized representative of a change in health condition.
Staff did not ensure that resident's hygiene needs were met.

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Jessica Cho regarding the allegations mentioned above and for the purpose of delivering findings. LPA Cho met with Administrator Mark Cruz and explained the purpose of the inspection by telephone at 3:51pm.

Regarding the allegation, Resident sustained an unexplained injury while in care, the following was revealed: It is alleged Resident 1 (R1) sustained bruising on their right arm and a swollen or sprained left ankle and Staff 1 (S1) was unaware of how R1 became injured. Interviews were conducted with one staff and one witness. LPA attempted to conduct additional interviews with current facility residents, however, there are no facility residents remaining from the original date when the complaint was received. R1 could not be interviewed due to their passing on June 30, 2022. During interview, R1’s responsible party, Witness 1 (W1) stated that on April 28, 2021, R1 had a fall and had a bruise over their left eye on their forehead, discoloration on their left eye lid, and a scrape on their nose. Per W1, they advised the Hospice Agency providing care for R1 and they responded to check on R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

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 4

Control Number 22-AS-20210907113019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TESSA'S PLACE 1	FACILITY NUMBER: 306005907
	VISIT DATE: 06/16/2026

NARRATIVE

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W1 stated they were informed that in order to have R1 further evaluated, they would have to remove R1 from hospice care; therefore, W1 stated they did not take R1 to the hospital or call R1’s neurologist. W1 was unable to provide additional evidence of alleged injuries. Per W1, on August 28, 2021, they visited R1 at the facility and upon removing R1’s left shoe, they observed R1’s ankle was swollen and asked S1 if R1 had fallen but S1 was unable to confirm or deny if R1 had fallen. W1 was unable to provide additional evidence of R1’s swollen ankle. Per W1, they also observed three bruises on R1’s right forearm and stated they were caused by a caregiver, however, W1 was unable to identify the caregiver. During interview, Administrator (AD) denied the allegation and stated R1 was never hurt at the facility and they “only saw one discoloration” that was caused by R1 trying to open the screen door and that had been reported to W1. Per AD, S1 had not been employed by the facility since September 2021, and they no longer had any contact information for them, thus S1 could not be interviewed to verify W1’s statements. LPA also attempted to contact Hospice Agency providing care to R1, however, the Agency is no longer operating.

Regarding the allegation, Staff mismanaged resident's medication, the following was revealed: It is alleged that on August 27, 2021, facility staff received an antibiotic for R1 from the pharmacy but placed the medication away in a cabinet and did not start the dosage when received. During interview, W1 stated that on August 27, 2021, they were contacted by a Hospice Nurse who informed them they were able to obtain a urine sample from R1 and determined R1 had a Urinary Tract Infection (UTI) and the doctor wanted to prescribe antibiotics. W1 stated they agreed and personally called the pharmacy. Per W1, they were informed the medication would be delivered to the facility prior to the end of the day so that R1 could start the treatment. W1 stated that on August 28, 2021, they visited R1 at the facility and asked if R1 had their antibiotic that morning. Per W1, S1 informed them they had never received the medication from the pharmacy the night before. W1 stated they immediately called the pharmacy and asked why the antibiotic had not been delivered. Per W1, they were informed the medication had been delivered and given to an unidentified female staff at the facility. W1 stated they requested the closet where medication was stored be checked and staff retrieved two brown bags, one of which one was folded and stapled closed and contained R1’s antibiotic medication. Per W1, they informed Licensee that S1 had not given R1 their antibiotic medication and had not even opened it after it was delivered the night before. W1 stated they advised Licensee they would be removing R1 from their care and on August 29, 2021, they moved R1 to another facility. During interview, AD stated that due to R1 being moved out of the facility on August 29, 2021, they were unable to recall if the medication had been received or administered.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20210907113019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TESSA'S PLACE 1	FACILITY NUMBER: 306005907
	VISIT DATE: 06/16/2026

NARRATIVE

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Per AD, they no longer had any contact information for S1 since their end of employment in September 2021, thus S1 could not be interviewed to verify W1’s statements. During the course of the investigation, LPA obtained a copy of R1’s Centrally Stored Medication and Destruction Record (LIC622) and observed medication in question to be listed with a start date of August 28, 2021, however, LIC622 does not indicate if medication was received or present at the facility on August 27, 2021.

Regarding the allegation, Staff did not inform resident's authorized representative of a change in health condition, the following was revealed: It is alleged that W1 was not notified of a change in R1’s condition on at least on occasion. During interview, W1 stated that on August 12, 2021, they visited R1 at the facility and were asked by S2 why a particular routine medication for R1 had been discontinued. W1 stated it had not been discontinued and inquired why S2 was asking. Per W1, S2 informed them that the night of August 7, 2021 had been the last time R1 had received that routine medication and stated they had asked the Hospice Agency why the medication has been discontinued and the Hospice Licensed Vocational Nurse (LVN) had stated the medication had been discontinued two months ago. W1 stated they contacted the owner of the Hospice Agency, who advised them the LVN had been looking at the wrong medication list for R1 and therefore the medication had not been sent by the pharmacy. Per W1, the medication was then delivered to the facility prior to 7:00 p.m. that night and administered to R1. Per W1, they spoke with Registered Nurse (RN) and Manager of LVNs at the Hospice Agency and informed them they did not want that specific LVN to be assigned to R1 any further due to giving the wrong information to facility staff. Per W1, they informed AD that S2 should not be in any trouble due to having been the only one who had attempted to advise the Hospice Agency about the “lack of” medication. W1 further stated that on August 28, 2021, when visiting R1 at the facility, they observed R1 to be “lethargic” and they had not been informed of this change in condition. Per W1, R1 was “very incoherent,” could not lift their head, and appeared “like a woman with osteoporosis.” During the course of the investigation, LPA obtained a copy of R1’s Physician Report (LIC602A) dated May 14, 2021 which indicated R1 had a history of concussions, Traumatic Brain Injury (TBI), generalized body weakness, and was non-ambulatory. During interview, AD denied R1 having any change in condition while they were a resident at the facility and stated the only change of condition had been R1’s appetite, “some days [R1] would eat well and other days not.” Per AD, they always kept W1 informed and even provided them with daily updates on R1. AD stated W1 was “actually always” at the facility and when W1 was not there, would call three to four times per day to speak to staff and R1. AD stated W1 “would even request to go in other resident files” and they would “constantly” have to explain confidentiality requirements and personal rights.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20210907113019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TESSA'S PLACE 1	FACILITY NUMBER: 306005907
	VISIT DATE: 06/16/2026

NARRATIVE

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During the course of the investigation, former Resident 2 (R2) was interviewed and stated that W1 was very rude.

Regarding the allegation, Staff did not ensure that resident's hygiene needs were met, the following was revealed: It is alleged R1’s hygiene needs were not met. During interview, W1 stated that due to incontinence issues, staff should have been bathing R1 daily. Per W1, on August 22, 2021, they visited R1 at the facility and when they arrived, they noticed R1’s hair had not been washed and “was very oily.” W1 stated they asked S1 why R1 had not had a shower and S1 stated they were waiting for the Hospice Nurse to come and give R1 a shower. Per W1, they became “upset” and informed S1 that R1 needed a shower daily and the Hospice Assistants only come twice a week. W1 stated they informed the Licensee they did not want S1 to take care of R1 any further and on August 29, 2021, W1 moved R1 to another facility. During interview, AD stated R1 received two showers from the Hospice Agency per week, plus daily showers from care staff at the facility. Per AD, when being showered, R1 would make facial gestures when staff would get their hair wet and “it was apparent that [R1] didn't like [their] hair wet, so staff respected that”, however, W1 wanted R1’s hair to be washed daily. Per AD, S1 had not been employed by the facility since September 2021, and they no longer had any contact information for them, thus S1 could not be interviewed to verify W1’s statements. LPA also attempted to contact Hospice Agency providing care to R1, however, the Agency is no longer operating.

Based on investigations and conflicting information received during interviews conducted, the Department did not find sufficient evidence to support the allegations, “Resident sustained an unexplained injury while in care, Staff mismanaged resident's medication, Staff did not inform resident's authorized representative of a change in health condition, and Staff did not ensure that resident's hygiene needs were met.” Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report was provided at the end of the inspection.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC9099 (FAS) - (06/04)

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