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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003655
Report Date: 12/11/2025
Date Signed: 12/11/2025 04:46:23 PM

Document Has Been Signed on 12/11/2025 04:46 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TESSIE'S PLACE LOVING CARE HOME #2FACILITY NUMBER:
306003655
ADMINISTRATOR/
DIRECTOR:		ROMUALDO AMANTEFACILITY TYPE:
740
ADDRESS:27021 MISSION HILLS DR.TELEPHONE:
(949) 443-1496
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 5DATE:
12/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Romualdo Amante, administrator (via phone)TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Romualdo Amante was notified via telephone and could not assist in person

There are currently five residents in care, three of which are receiving hospice care at this time out of a waiver capacity of two. Deficiency cited. Residents are observed relaxing in their respective bedrooms and in the common areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with four private and one shared bedrooms used by residents in addition to one staff room. There are two bathrooms used by residents. None of the residents are bedridden at this time.

All occupied bedrooms appear clean and sanitary. There are four beds equipped with full rails or combined half-rails. Two residents have no orders on file. Citation issued. One resident not receiving hospice care also has a bed with full rails. Deficiency cited.All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are all equipped with grab bars and slip mats. Hot water temperature measured at 114F in two bathrooms with faucets used for personal grooming.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secure.

CONTINUED ON FORM LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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 6
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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Document Has Been Signed on 12/11/2025 04:46 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/11/2025 at 04:13 PM
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: TESSIE'S PLACE LOVING CARE HOME #2
FACILITY NUMBER: 306003655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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 observation, the licensee did not comply with the section cited above as the two fire extinguishers present display outdated maintenance tags dated December 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2025
Plan of Correction
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Licensee will conduct a fire extinguisher maintenance and provide proof thereof to licensing staff
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents, Facility is 1 resident above their current hospice waiver which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2025
Plan of Correction
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Licensee agrees to request a hospice waiver increase and to submit a statement showing they have read and understand and agree to comply with CCR 87204 and CCR 87633.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 04:46 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/11/2025 at 04:13 PM
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: TESSIE'S PLACE LOVING CARE HOME #2
FACILITY NUMBER: 306003655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above as annual training records for staff member S1 only display relevant annual training for 2024 and nothing on file for 2025. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2025
Plan of Correction
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Annual training for S1 to be conducted and documented before the plan of corrections due date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, the licensee did not comply with the section cited above as multiple residents whose beds are equipped with postural supports do no have any physician orders on file. This constitutes a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2025
Plan of Correction
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Licensee will obtain physician orders for all residents requiring the use of postural supports prior to the plan of corrections due date. Orders to be submitted for review to licensing staff.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 04:46 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/11/2025 at 04:13 PM
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: TESSIE'S PLACE LOVING CARE HOME #2
FACILITY NUMBER: 306003655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, the licensee did not comply with the section cited above as a total of four beds equipped with full rails or two half-rails back-to-back are observed on the premises, even though only three residents are admitted onto hospice at the time of the visit. This constitutes a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2025
Plan of Correction
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Full rails to be substituted with half rails with relevant physician orders for residents not admitted on hospice.
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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TESSIE'S PLACE LOVING CARE HOME #2
FACILITY NUMBER: 306003655
VISIT DATE: 12/11/2025
NARRATIVE
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CONTINUED FROM FORM LIC809
Fire extinguishers are present and verified to be charged, however their maintenance tags are dated December 2022 and are therefore out of date. Type B deficiency cited. Carbon monoxide and smoke detectors are present and operational.

LPA and facility staff toured the outside of the facility. LPA observed multiple shaded outdoor seating areas with outdoor furniture for resident use in the backyard. The identified routes of egress are free of clutter and obstructions. There are self-latching gates on both sides of the premises. There are no bodies of water on the premises and the facility does not utilize either locked perimeters or delayed egress.

LPA reviewed five resident records. LPA reviewed resident medication records and prescription orders with no discrepancies observed for four residents.

LPA reviewed staff records for four staff members during the visit. All staff members on the schedule are background cleared and associated. Proof of current CPR training reviewed. Annual and initial training reviewed and found to be missing for staff member S1. Deficiency issued. Disaster drills are conducted quarterly. The administrator certificate is current.

Based on the observations conducted during the present visit, five type B deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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