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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005907
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:56:53 PM

Document Has Been Signed on 11/09/2022 12:56 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:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Mark CruzTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Tessa's Place 1 to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 10:24am, LPA Cho was greeted and granted entry by Caregiver Evangelyn Pablo. Also present were Caregivers Maria Morelos and Domingo Morelos. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a check-in station with temperatures of visitors documented on the sign-in sheet. LPA observed the required COVID-19 precautionary signs posted on the front entrance and throughout the facility. The Complaint Poster (PUB475) met the Department size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently six residents living in the facility of which three are receiving hospice care. The Administrator's Certificate for Eleonor Avendano expires on 10/28/2023 and on 12/02/2022 for Mark Cruz. Administrator Mark Cruz arrived at the facility approximately 10:40am.

At 10:46am, LPA Cho conducted a tour of the physical plant with Administrator Mark Cruz..There are a total of four resident bedrooms and three resident bathrooms. There is a private staff bedroom. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and slip mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked with hand soaps and paper towels. LPA observed hand washing signs in the bathrooms. The hot water temperature in the resident bathrooms measured at 111.4 degrees Fahrenheit in resident Bathroom #1, 110.6 degrees Fahrenheit in resident Bathroom #2, and 111.3 degrees Fahrenheit in Bathroom #3. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were mounted, fully charged, and serviced on 03/08/2022.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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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: TESSA'S PLACE 1
FACILITY NUMBER: 306005907
VISIT DATE: 11/09/2022
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 Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. The exit gates were self-closing and self-latching. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit. An exit interview was conducted with Administrator Mark Cruz, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
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