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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004335
Report Date: 03/04/2025
Date Signed: 03/05/2025 07:53:00 AM

Document Has Been Signed on 03/05/2025 07:53 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: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: 6DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Ilse Berenice/ Rama PichikaTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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On this day Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, of which three may be bedridden. Facility has an approved hospice waiver for 3 residents and the home currently has 6 residents and one tenant. Administrator Jaya Pichika has a current administrator certificate expiring on 09/13/2025.

LPA Lyman along with Caregiver Berenise toured the facility at 12:41 PM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The two story home consists of 6 resident bedrooms, tenant room, owner occupied room, living room, dining room, and kitchen as well as 4 restrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident 2 (R2) has a faulty smoke detector in the resident's room. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. R1's shower handle is observed to be broken and R3's door handle is broken. Water temperature measured between 107 degrees F and 134.7 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. The downstairs common restroom has discoloration on door and a taped hole in the wall outside the restroom. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. LPA observed rotten tomatoes, bell peppers, cauliflower and green beans as well as out of date milk in the refrigerator. Smoke detectors tested operational during today's visit. Fire extinguisher is fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise and LPA observed residents participating in exercise.
CONTINUED ON LIC 809C DATED 03/04/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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: 03/04/2025
NARRATIVE
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LPA observed the emergency food and water supply. LPA reviewed six resident files and one staff file. All resident files contained required documentation including admission agreements, physician reports and resident appraisals. R5 does not have a physician order for bed rails. One out of two staff present do not have a staff file.

Licensee to forward an updated LIC 500 to LPA by 03/18/2025. Due to time constraints, LPA to return to conduct medication audit.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/05/2025 07:53 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/04/2025 at 02:50 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of two staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
1
2
3
4
Licensee to obtain CPR/ First aid training for staff and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87303(e)(2)
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. Facility water temperature measured 134.7 which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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3
4
Licensee to adjust water temperature and forward proof to LPA by POC due date.
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: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/05/2025 07:53 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/04/2025 at 03:02 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed multiple soiled/ out of date food items.
POC Due Date: 03/18/2025
Plan of Correction
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2
3
4
Licensee to forward a statement of understanding to LPA by POC due date.
Type B
Section Cited
CCR
87608
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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4
Based on record review, the licensee did not comply with the section cited above. Resident 5 does not have physician orders for bed rails which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee to obtain physician order for bed rails and forward to LPA by POC due date.
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: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/05/2025 07:53 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/04/2025 at 03:14 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Licensees shall maintain in the personnel records verification of required staff training and orientation.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above. Staff 1 does not have proof of training maintained in personnel reocrd which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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2
3
4
Licensee to maintain proof of training in staff file and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/05/2025 07:53 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/04/2025 at 03:48 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(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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2
3
4
Based on observation, the licensee did not comply with the section cited above in [noted items on LIC 809 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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2
3
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Licensee to repair/ replace noted items on LIC 809 and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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