306005910-2-15-2022-22-AS-PVEZ-CBNPYJ-20220215104401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005910
Report Date: 02/15/2022
Date Signed: 02/15/2022 10:44:06 AM

Document Has Been Signed on 02/15/2022 10:44 AM - 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:	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: 5	DATE:	02/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Mark Ryan Cruz - Administrator		TIME COMPLETED:	10:55 AM

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	Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Tessa's Place 3. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and initially met with Caregiver Maria Magdalena Eguico. Administrator (AD) Mark Cruz arrived shortly after LPA's arrival. The facility is licensed for 6 non-ambulatory residents. The facility also has an approved hospice waiver for 6 residents. There are currently 5 residents living in the facility. The last emergency disaster drill was conducted on January 31, 2022. At 9:20 AM LPA Velazquez conducted a tour of the physical plant along with Caregiver Eguico and then with AD Cruz. The 1 story home consists of 4 resident bedrooms and 1 staff bedroom with 3 bathrooms. LPA observed several cameras throughout the facility in the common areas. AD indicated the cameras were approved when the facility was initially licensed. The 5 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails on the beds of some of the residents. LPA was informed that these residents were receiving hospice services. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature ranged from 120.2 to 127.4 degrees Fahrenheit. LPA immediately notified AD so that the temperature could be lowered. AD proceeded to call his maintenance staff. LPA Velazquez inspected the kitchen with AD Cruz. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Toxins, sharps, and medications were locked and inaccessible to

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: 02/15/2022

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
26
27
28
29
30
31
32

residents. First aid kit was checked and found to be in order. The facility did not have a First Aid manual and advised to obtain one. AD Cruz ordered a First Aid manual and provided LPA Velazquez with proof of purchase.

LPA Velazquez along with AD Cruz toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gates were operational. The auditory alarms were noted to be in operating condition. There were no security bars or weapons on the premises.

No client or staff files were reviewed at the time of this visit. LPA Velazquez observed bed rail orders for residents with bed rails.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Mark Cruz and a copy of this report along with the appeal rights and a copy of the LIC 9098 was provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/15/2022 10:44 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintanence and Operation.
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: The Licensee did not comply with this regulation as the hot water temperature was measured by LPA Velazquez and ranged from 120.2 to 127.4 degrees Fahrenheit. This poses an immediate risk to the health and safety of residents in care.
	POC Due Date: 02/16/2022
	Plan of Correction
1 2 3 4	Licensee to adjust the hot water temperature so that the range is between 105 and 120 degrees Fahrenheit and submit written proof to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3