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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004335
Report Date: 04/13/2022
Date Signed: 04/13/2022 01:30:17 PM

Document Has Been Signed on 04/13/2022 01:30 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TALEGA TERRACEFACILITY NUMBER:
306004335
ADMINISTRATOR:JAYALAKSH PICHIKAFACILITY TYPE:
740
ADDRESS:24 VIA ANDAREMOSTELEPHONE:
(949) 545-7574
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6CENSUS: 5DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Larry EspanolTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jessica Cho, Joseph Alejandre, and Celine DePerio conducted an unannounced annual visit to Talega Terrace. The purpose of the visit was to conduct the required annual inspection (mitigation). LPAs were greeted and granted entry after completing the Coronavirus 2019 (COVID-19) screening and met with Lead Caregiver. LPA Cho spoke to the Administrator (AD) Jayalaksh Pichika by phone. AD agreed and confirmed that the Caregiver will be assisting with the tour. The Administrator's Certificate expired on 9/13/19.

Facility is licensed for 6 non-ambulatory of which 3 may be bedridden, and has an approved waiver for 2 hospice residents. The facility consists of a two story building with 9 bedrooms and 5 bathrooms with a living room, dining room, kitchen, and a 2 car garage. Three out of the nine bedrooms and two out of the five bathrooms are for the caregivers. The first floor has 5 bedrooms and 2 bathrooms for residents. The fifth bedroom does not reflect on the current facility sketch. LPAs toured the facility with the Caregiver. All the residents' bedrooms met all regulatory compliance except for the following: LPAs observed a missing screen and night stand, exposed outlet, and a broken sliding door hinge to the closet in Bedroom 4. All bathrooms were clean and operational and all hot water ranged from 107.2 to 111.9 degrees Fahrenheit. The fire extinguishers were mounted and charged and the smoke and carbon monoxide detectors tested operational. LPAs observed the medications and sharp objects were locked. A two day perishable and a seven day non-perishable food items were observed. The stove lights unassisted. LPAs inspected the locked garage and observed the storage of food and cleaning supplies. The washer and dryer were located on the second floor and the laundry detergents were locked away in the bottom left cabinet.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TALEGA TERRACE
FACILITY NUMBER: 306004335
VISIT DATE: 04/13/2022
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LPAs observed the following: hard water stains in the shower and tub in Bathroom 5, drain cover in the exit passageway was missing, the outdoor garage light was not operational, the facility sketch was not updated to match the current bedrooms available in the facility.

LPAs inspected the exterior of the facility. LPAs observed the required chairs and tables under sufficient shading. LPAs observed an outdoor BBQ island and a courtyard. The left side of the facility led to a small courtyard and LPAs observed a small, elevated fountain with a diameter of 18 inches and a depth of 3 inches. The side gate to the right side of the facility was self-latching and tested operational. The auditory exit alarm on the side gate did not test operational. Facility has a pending mitigation plan.

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Based on the observations made during today's visit, deficiencies are being sited per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and the LPA will follow-up with the corrections. A civil penalty is being issued today for $100 due to background clearance transfer of the staff member was not completed. An exit interview was conducted with the facility representative and a copy of the report was provided as well as a copy of appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
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Document Has Been Signed on 04/13/2022 01:30 PM - It Cannot Be Edited


Created By: Jessica Cho On 04/13/2022 at 01:01 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: TALEGA TERRACE
FACILITY NUMBER: 306004335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)

Request a transfer of a criminal record clearance as specified in Section 87355(c) or
Deficient Practice Statement
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This requirement is not met as evidenced by: one out of two staff members are not associated to the facility. This poses an immediate health and safety risk to persons in care.
POC Due Date: 04/14/2022
Plan of Correction
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Licensee will associate the staff member to the facility.
Type A
Section Cited
CCR
87465(h)(2)

Centrally stored medicines shall be kept in a safe and locked palce that is not accessible to persons other than employees responsibe for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by: LPAs observed that medication for Resident 4 (R4) was stored in the bathroom cabinet. This poses an immediate health and safety risk to persons in care.
POC Due Date: 04/14/2022
Plan of Correction
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Licensee will remove and store away all medications where they are inaccessible to persons in care. This was corrected during the visit.
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:Sheila Santos
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


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Document Has Been Signed on 04/13/2022 01:30 PM - It Cannot Be Edited


Created By: Jessica Cho On 04/13/2022 at 01:08 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: TALEGA TERRACE
FACILITY NUMBER: 306004335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)

The administrator shall have the qualifications specified in Sections 87405(d)(1) through(7). If the licensee is also the administrator, all requirements for an administrator shall apply.
Deficient Practice Statement
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This requirement is not met as evidenced by: based on interview and review of documents, licensee did not have the qualifications for operation of facility. Adminstrator does not have a current certificate.
POC Due Date: 04/27/2022
Plan of Correction
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The administrator will complete all requirements for Administrator's Certification renewal and forward a copy of the Administrator's Certificate when complete.
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:Sheila Santos
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


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