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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005910
Report Date: 02/15/2024
Date Signed: 02/15/2024 04:58:16 PM


Document Has Been Signed on 02/15/2024 04:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 3FACILITY NUMBER:
306005910
ADMINISTRATOR:AVENDANO, ELEONORFACILITY TYPE:
740
ADDRESS:25982 VIA MAREJADATELEPHONE:
(949) 331-3822
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Mark Cruz- Administrator
Justin Cruz- Office Manager		TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to conduct the Required 1-Year Annual Inspection. LPA was greeted and granted entry after stating the purpose of the visit to Caregiver Maryrose Sagum. Administrator (Admin) Mark Cruz and Office Manager Justin Cruz arrived shortly after to assist with the inspection.

LPA conducted a tour of the physical plant accompanied by Caregiver Sagum and Admin Cruz. The following were observed: This is a single story facility comprised of four resident bedrooms and three resident bathrooms, laundry room/2-car garage, living/family room, and dining room. LPA toured the outside grounds. There was shading and sufficient seating for the residents. The exit gate was self-closing and self-latching.

LPA observed four residents and three caregivers on duty. The resident bedrooms are spacious and easily accommodates the residents' furnishings. Furniture for each resident bedrooms were inspected. The bathrooms were clean, faucets, toilets, and grab bars were operational. The hot water temperature measured at 118.5, 118.2, and 116.6 degrees Fahrenheit. There were sufficient supply of clean linens. LPA observed a two-day supply of perishables and a seven-day supply of non-perishable food as required per regulation. Carbon monoxide, smoke detectors, and the auditory devices were tested and operational. The fire extinguisher was serviced on 03/21/23. Medications, sharps, and toxins were locked and inaccessible to the residents. Facility had ample supply of emergency supplies including food/water and first aid kit. LPA reviewed four out of the four resident files and two out of the two staff files including resident medications.

Administrator was reminded on the following items: to conduct quarterly emergency drills of different variations, to accurately document when the medication was refused on the Medication Administration Record (MAR), and to dispense the medications matching the corresponding calendar date.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TESSA'S PLACE 3
FACILITY NUMBER: 306005910
VISIT DATE: 02/15/2024
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Based on the observations made during today's visit, no deficiency is being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations. Advisory Notes (LIC9102s) are being issued during the visit.

An exit interview was conducted with Administrator Mark Cruz and Office Manager Justin Cruz, and a copy of this report including the LIC809C, and the LIC9102s were provided at the end of this visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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