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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001351
Report Date: 08/22/2022
Date Signed: 08/22/2022 11:54:34 AM

Document Has Been Signed on 08/22/2022 11:54 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: 3DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sol Larcia, caregiver
Joseph Sampang, caregiver
Marites Villanueva, Administrator		TIME COMPLETED:
12:15 PM
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On 08/22/2022 at 10:40am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by caregivers Joseph Sampang and Sol Larcia. Administrator Marites Villanueva was notified by telephone and arrived shortly afterwards to assist with the visit.

At approximately 11:00am, LPA accompanied by administrator toured the physical plant of the facility. There are currently three (3) residents in care, one of which is documented to receive hospice care. Records for resident R1 have been requested and provided. Resident is noted as Non-Ambulatory in physician report but is stated by Administrator to be bedridden. R1 was admitted on hospice on 08/02/2022.

The other residents are observed relaxing in the common area or in their bedroom and appear clean and well taken care of. The four (4) bedrooms include all necessary components. An ample supply of linen is observed. The shared bathroom is equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are stored in a kitchen cabinet secured by a key lock. The centrally stored medication and resident files are located in a locked cabinet in the laundry area, where cleaning supplies are also located and secured. LPA observed a sufficient supply of food and water present.

LPA observed the facility has COVID-19 Precautions posters and all required department postings. Staff present is adequately cleared and associated in Guardian. The fire extinguisher present is mounted and charged. It has been serviced in November 2021.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 306001351
VISIT DATE: 08/22/2022
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CONTINUED FROM FORM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area is present for the enjoyment of residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory is issued regarding retaining bedridden residents. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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