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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004335
Report Date: 10/11/2024
Date Signed: 10/11/2024 03:37:44 PM

Document Has Been Signed on 10/11/2024 03:37 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/
DIRECTOR:		JAYALAKSH PICHIKAFACILITY TYPE:
740
ADDRESS:24 VIA ANDAREMOSTELEPHONE:
(949) 545-7574
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6CENSUS: DATE:
10/11/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:16 PM
MET WITH:Jay PichikaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Manager (LPM) Alisa Ortiz, and Licensing Program Analyst (LPA) Kimberly Lyman, conducted an informal office meeting with Licensee Jaya Pichika to discuss general compliance concerns at the facility.
The following items were discussed during the meeting:
  • Staffing levels and schedule.
  • Physical plant issues.
  • Lack of communication between licensee and the department.
  • Non-compliance with citations.
  • Licensing fees
  • Reporting requirements
Licensee agrees as follows:
  • Licensee to communicate with the department on all issues or concerns regarding facility operations.
  • Licensee agrees to contact department for clarification and not make assumptions.
  • Licensee to forward a copy of the LIC 500 to LPA by 10/14/2024 that ensures coverage during hours when residents require services.
  • Facility will maintain compliance of Title 22 at all times and failure to maintain compliance may result in the department taking further action.
During the visit, Licensee was offered technical support services with the department and Licensee agreed to a referral for the service.

Based on the observations made, deficiency is being sited per Title 22 Division 6 Chapter 8 of the California Code of Regulations. 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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 10/11/2024 03:37 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/11/2024 at 07:46 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: TALEGA TERRACE
FACILITY NUMBER: 306004335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
87156

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An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.
This requirement is not being met as evidenced by:
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Licensee to pay fees and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure billed licensing fees have been paid. Licensee owes $1484. This poses a potential health and safety risk to residents in care.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024


LIC809 (FAS) - (06/04)
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