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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006097
Report Date: 07/18/2024
Date Signed: 07/19/2024 03:58:30 PM


Document Has Been Signed on 07/19/2024 03:58 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
Lookup Error,
, CA



FACILITY NAME:TESSA'S PLACE 4FACILITY NUMBER:
306006097
ADMINISTRATOR:AVENDANO, ELEONORFACILITY TYPE:
740
ADDRESS:2825 CALLE GUADALAJARATELEPHONE:
(949) 331-3822
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 4DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:CoAdministrator Mark CruzTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Rowena Manalili, Co-Administrator Mark Cruz and House Manager Justin Cruz arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six residents, of whom all may be non-ambulatory.

LPA toured the interior and exterior of the facility and inspected each room. The kitchen had dirty floors, sticky and disorderly cabinets. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. One resident bedroom had a stand alone air conditioner that was collecting condensation water into a bucket, such bucket was almost full and sitting in residents room. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas.

No pool or body of water was present. Water temperature was measured at 105.3 degrees F in the kitchen and 89 degrees F in resident bathroom. Per Mark, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were present. First aid kit was complete. Resident records reviewed had required documentation. Needs and Services plans were not signed by resident or responsible party. Hospice resident full bed rail orders were observed. Staff records reviewed contained required documentation.

One technical violations was issued for unsigned Needs and Services Plans, three additional deficiencies were cited for physical plant. An exit interview was conducted with Co-Administrator, to whom a copy of this report, LIC9099D (x2) and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
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


Document Has Been Signed on 07/19/2024 03:58 PM - 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
Lookup Error,
, CA


FACILITY NAME: TESSA'S PLACE 4
FACILITY NUMBER: 306006097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews the licensee did not comply with the section cited above in 4 out of 4 residents in care which poses a potential health risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee removed water bucket collecting condesation while LPA was present and cleaned resident's vacant room. Plan of correction cleared on today's date.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews the licensee did not comply with the section cited above in 4 out of 4 residents in care which poses a pontential health risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee agrees to provide a thorough cleaning of kitchen floors and cabinets by POC date.
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: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/19/2024 03:58 PM - 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
Lookup Error,
, CA


FACILITY NAME: TESSA'S PLACE 4
FACILITY NUMBER: 306006097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above in two of four residents which poses personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee agrees to fix the faucet delievering the lower temperatures by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3