306005910-12-23-2020-22-AS-MBAT-BWKSLN-20201223125837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005910
Report Date: 12/23/2020
Date Signed: 12/23/2020 01:00:41 PM

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:	TESSA'S PLACE 3		FACILITY NUMBER:	306005910
ADMINISTRATOR:	AVENDANO, ELEONOR		FACILITY TYPE:	740
ADDRESS:	25982 VIA MAREJADA		TELEPHONE:	(949) 331-3822
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	12/23/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Applicants Eleonor and Reiner Avendano		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 11:00 AM, Licensing Program Analyst (LPA) Mike Barrett contacted the facility via FaceTime application, using iPhone technology, to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the announced video call and spoke with Applicants Eleonor and Reiner Avandano. The facility contains 5 bedrooms with 3 full bathrooms is a single-story building with a 2-car garage. This pre-licensing inspection was due to a change in ownership and at the time of the inspection there were 6 residents living in the facility. The inspection was as follows: Physical Plant: At 11:10 AM, LPA Barrett conducted the virtual inspection and toured the inside and outside of this facility with the applicants, including but not limited to the kitchen, common areas, laundry room, garage, bathrooms, bedrooms, back patio and walkways. LPA observed that the facility was clean, there were no obstructions to the interior or exterior walkways and the backyard gate was observed to be self-closing and self-latching. The kitchen was clean, and knives were stored in a locked drawer. There were smoke/carbon monoxide detectors installed throughout common areas as well as all of the bedrooms which are centrally wired and observed to be operational. LPA observed that there were alarms installed on all of the exit doors that were observed to be functional. Fire extinguisher was located in the dining room and was observed to be appropriately charged and mounted. Centrally Stored medications were observed to be stored in a locked closet which also contained personal protective equipment (PPE), disaster plan and a complete first aid kit . Bedrooms: Bedrooms were observed to have made beds, bedroom furniture, appropriate lighting and exit doors were free of obstructions. Continued on page 2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

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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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: TESSA'S PLACE 3	FACILITY NUMBER: 306005910
	VISIT DATE: 12/23/2020

NARRATIVE

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Continued from page 1.

Bathrooms:
Bathrooms were equipped with grab bars and non-skid mats in the shower stalls and the water temperatures from the faucets measured 115.0, 110.0 and 115.0 degrees F. The facility also equipped the toilets with handled, raised commodes.

Supplies:
There was a sufficient supply of paper products and hand soap as well as a sufficient stock of linens in the hall closets.

Food Service:
The facility met the 2-day perishable and 7-day nonperishable on hand food supply as LPA observed fresh fruit, canned goods, bread, dairy products, pasta, eggs, frozen meats and cereals in the kitchen and pantry, refrigerator and freezer. The food was observed to be stored appropriately and away from cleaning supplies.

Records:
Staff and Resident files were kept off site with a plan to keep them in the facility following licensure.

Administration:
LPA observed and reviewed the facility’s Emergency Disaster Plan, Resident Personal Rights and “Let-Us-No” poster posted in the facility.

Activities:
The activities schedule was posted on the information board just outside of the kitchen area.

The Component III Orientation was waived due to LPA had conducted the orientation with the applicants on 5/6/2020 during an inspection of another licensed facility.

Per the passing of this inspection, LPA Barrett recommends this facility for licensure. A telephonic exit interview was conducted with ED, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

LIC809 (FAS) - (06/04)

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