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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005909
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:21:44 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2021 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210827132314
FACILITY NAME:TESSA'S PLACE 2FACILITY NUMBER:
306005909
ADMINISTRATOR:AVENDANO, ELEONORFACILITY TYPE:
740
ADDRESS:25321 DE SALLE DRIVETELEPHONE:
(949) 331-3822
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 6DATE:
06/21/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Mark Cruz, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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-Illegal eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted at the door by caregiver and granted entry. LPA spoke with Mark Cruz, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included file review, OC Sheriff police report and interviews conducted.

It is alleged that facility gave resident an illegal eviction. Upon review of records reflect that on 08/09/2021 resident (R1) had an incident with other facility residents. Incident resulted in facility Administrator contacting OC Sheriff to file a report. Review of OC Sheriff police report dates 08/10/2021 indicates interviews were conducted with residents at the facility. Report indicates that R1 had very little to say but stated R1 "would not

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20210827132314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2
FACILITY NUMBER: 306005909
VISIT DATE: 06/21/2022
NARRATIVE
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do it again". Interview with staff (S1) revealed that based upon the incident involved facility was made assessment that facility was unable to meet resident’s needs. Administrator then informed the family of R1. Until R1 was reassessed and found new placement a private companion for R1 at night was provided as a tool for intervention. This intervention was paid and provided by the facility in order to provide a safer environment for residents. Administrator provided assistance to RN case manager from assisted living waiver program in order to evaluate R1 for an update lever of care assessment. R1 was moved out and relocated to a skilled nursing facility on 08/20/2021. Upon review of records there is no indication that a 3 day notice was given to R1 for eviction. Base on the information received from interviews, the lack of information regarding the illegal eviction, and the lack of corroborating witnesses to the incident, LPA is unable to determine if the alleged violation occurred as reported.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2