370804859-4-1-2025-08-AS-LSIA-DFBAT9-20250401002959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370804859
Report Date: 03/28/2025
Date Signed: 04/01/2025 12:30:39 AM

Document Has Been Signed on 04/01/2025 12:30 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	TESSIE BOARD AND CARE		FACILITY NUMBER:	370804859
ADMINISTRATOR/ DIRECTOR:	PEDROSO, TERESITA		FACILITY TYPE:	740
ADDRESS:	7229 ZEST STREET		TELEPHONE:	(619) 773-6360
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY: 5	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:15 PM
MET WITH:	Licensee Tessie Pedroso		TIME VISIT/ INSPECTION COMPLETED:	04:15 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) Liliana Silveira conducted an unannounced required annual inspection. LPA identified herself, disclosed the purpose of the visit, and was granted entry into the facility by Caregiver Ophyl Elkins. 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) elderly residents, three of whom may be non-ambulatory in Rooms 1 and 4. During today’s inspection, there were 5 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 #1 was 111 F and bathroom #2 was 109 F. 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. (CONTINUED ON NEXT PAGE, LIC 809C)

Robyn Clark	TELEPHONE: (619) 767-2312
Liliana Silveira	TELEPHONE: (619) 481-0844
	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TESSIE BOARD AND CARE	FACILITY NUMBER: 370804859
	VISIT DATE: 03/28/2025

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LPA interviewed residents. Interviews did not raise any licensing concerns. LPA also reviewed staff and resident records/files. All files contained required documents. Confidential records were stored in a locked area.

No citations or deficiencies were issued during this inspection.

An exit interview was conducted with Tessie Pedroso, to whom a copy of this report,and the Licensee/Appeal Rights (LIC9058 03/22) were provided. The signature on the report confirms receipt of documents.

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

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