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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005907
Report Date: 02/09/2022
Date Signed: 02/09/2022 03:23:58 PM

Document Has Been Signed on 02/09/2022 03:23 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:TESSA'S PLACE 1FACILITY NUMBER:
306005907
ADMINISTRATOR:AVENDANO, ELEONORFACILITY TYPE:
740
ADDRESS:26075 ARCADA DRIVETELEPHONE:
(949) 331-3822
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
02/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Maria Cecelia Morelos and Mark CruzTIME COMPLETED:
03:50 PM
NARRATIVE
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This unannounced visit conducted by Licensing Program Analysts (LPAs) Kimberly Lyman and Claudia Gutierrez is being conducted in conjunction with complaint visit 22-AS-20220207165233. LPAs arrived at facility and were greeted and granted entry by caregiver Maria Cecelia Morelos. LPAs met with Mark Cruz, Administrator, and explained the nature of the visit.

During the complaint visit, LPAs toured the facility and observed the following: Unsecured medications are sitting on the counter in the dining room. Medications include pre-poured medications as well as Amoxicillin and Tylenol. LPAs tested the smoke detectors in the facility and 5 out of 6 were operational. The smoke detector in the Caregiver room did not have batteries in the unit.



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 Administrator and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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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Document Has Been Signed on 02/09/2022 03:23 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 02/09/2022 at 02:57 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: TESSA'S PLACE 1
FACILITY NUMBER: 306005907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2022
Section Cited
CCR
87465(h)(2)

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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not being met as evidenced by:
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Licensee secured items during visit. CLEARED DURING VISIT.
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Based on observation, Licensee failed to ensure medications are secured and centrally stored. LPAs observed unsecured pre-poured medications as well as Amoxicillin and Tylenol. This poses an immediate health and safety risk to residents in care. (photos)
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Type A
02/10/2022
Section Cited
CCR87303(a)

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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 req is not being met as evidenced:
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LIcensee replaced batteries during visit. CLEARED DURING VISIT
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Based on observation, Licensee failed to ensure smoke detector was in good repair. LPAs observed smoke detector in Caregiver room is inoperable. This poses an immediate 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: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022


LIC809 (FAS) - (06/04)
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