370804859-2-12-2024-08-AS-DSEA-D2DTMH-20240212135110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370804859
Report Date: 02/12/2024
Date Signed: 02/12/2024 04:19:11 PM

Document Has Been Signed on 02/12/2024 04:19 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	TESSIE BOARD AND CARE		FACILITY NUMBER:	370804859
ADMINISTRATOR:	PEDROSO, TERESITA		FACILITY TYPE:	740
ADDRESS:	7229 ZEST STREET		TELEPHONE:	(619) 773-6360
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY:	5	CENSUS: 4	DATE:	02/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Teresita Pedroso, Licensee		TIME COMPLETED:	02:00 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	Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced required annual inspection. LPA identified herself, disclosed the purpose of the visit, and was granted entry into the facility. Licensee, Tessie Pedroso, to whom LPA disclosed the purpose of the visit, arrived a short time later. According to the facility’s license, the facility is licensed for five (5) residents, three of whom may be non-ambulatory in Rooms 1 and 4. During today’s inspection, there were four (4) residents in care. LPA, accompanied by licensee, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Windows screens were present and doors, sinks, and toilets were in working order. Hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate visitation, meetings, and activities. The facility's internal temperature was 70 degrees Fahrenheit. Hot water temperature in sink in bathroom that is used by residents measured at 117 degrees Fahrenheit. A fireplace with appropriate screening was observed in the living area of the home. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, and facility telephone were all in working order. Refrigerator and freezer were operational. There was at least 2 days of perishable food and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. Medications were labeled, as required, and stored in a locked cabinet. First aid kit was complete and readily accessible.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TESSIE BOARD AND CARE	FACILITY NUMBER: 370804859
	VISIT DATE: 02/12/2024

NARRATIVE

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LPA interviewed residents. Interviews did not raise any licensing concerns. LPA also reviewed staff and resident records/files. Resident 1’s (R1) file contained a Physician’s Report; however, the last two pages of the report were missing. Resident 2’s (R2) file did not contain a completed Physician’s Report. Staff file contained proof of current first aid and negative TB test result. Confidential records were stored in a locked area.

A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Tessie Pedroso, to whom a copy of this report, the LIC 809-D, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/12/2024 04:19 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TESSIE BOARD AND CARE	FACILITY NUMBER: 370804859
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 802 (Rev 9/89), Physicians Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 4 (R1 and R2) resident records, which poses a potential health risk to persons in care.
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	Licensee offered to obtain completed Physician's Reports for R1 and R2 and provide copies of the reports to Community Care Licensing by the POC due date of 3/11/2024.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

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