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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001351
Report Date: 11/30/2021
Date Signed: 12/01/2021 09:05:54 AM

Document Has Been Signed on 12/01/2021 09:05 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:TESS LOVING HOME IIFACILITY NUMBER:
306001351
ADMINISTRATOR:MARITES VILLANUEVAFACILITY TYPE:
740
ADDRESS:2785 E. DIANA AVE.TELEPHONE:
(714) 630-0999
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 5DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marites VillanuevaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez met and was granted entry by Staff Soledad Larcia. Staff Larcia confirmed there are currently no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility. Licensee/Administrator Marites Villanueva Jarcia arrived shortly after.

LPA observed the required Department posting on COVID-19 precautions at entrance of facility. There is a sign-in procedure in place and hand sanitizer for use. LPA observed that all staff were wearing face masks. The facility has an approved Mitigation Plan on file with CCLD. There were 5 residents present during this visit, 3 receiving Hospice Services. LPA conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. LPA toured all resident rooms, all rooms were within regulations. Residents were in their room and appeared relaxed. Restroom observed contained soap, toilet paper, paper towels, and had the proper hand washing signs posted. Facility has operating smoke and carbon monoxide detectors. Facility has Fire Extinguishers which was last charged on 09/04/2019. LPA observed a copy of Administrators Certificate which expires on 12/12/2021. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted, and a secured location for resident's medication and files. Facility has 30 days supply of medications for the residents. Residents emergency contact information and Physicians reports are current. LPA reviewed resident files.

Based on the observations made during the visit, the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report, along with Appeals Rights, Confidential Names (Lic811), LIC9102 TA) was discussed with the Administrator and copies will be emailed.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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Document Has Been Signed on 12/01/2021 09:05 AM - It Cannot Be Edited


Created By: Lydia Martinez On 11/30/2021 at 10:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TESS LOVING HOME II
FACILITY NUMBER: 306001351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation Licensee did not comply with the section cited above in that Fire Extinguisher was not serviced per regulation. LPA observed Fire Extinguisher to be last serviced on 09/04/2019. This poses an immediate health, safety and/or personal risk to the residents in care.
POC Due Date: 12/01/2021
Plan of Correction
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Licensee will ensure the Fire Extinguisher is maintained annually as required. Will replace or have the Fire Extinguisher serviced by POC due date and submit proof of correction to CCLD by 12/01/2021
Section Cited
Deficient Practice Statement
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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:Marina Stanic
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021


LIC809 (FAS) - (06/04)
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