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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005910
Report Date: 01/10/2025
Date Signed: 01/10/2025 11:48:00 AM

Document Has Been Signed on 01/10/2025 11:48 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TESSA'S PLACE 3FACILITY NUMBER:
306005910
ADMINISTRATOR/
DIRECTOR:		AVENDANO, ELEONORFACILITY TYPE:
740
ADDRESS:25982 VIA MAREJADATELEPHONE:
(949) 331-3822
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
01/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Mark Cruz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 8am. During today’s visit, LPA met with Justin Cruz, Office Manager and .Mark Cruz, Administrator (AD).

The facility is a single story residential home with four resident rooms, one staff room and an approved fire clearance of six non-ambulatory residents; of which six may be on hospice. The facility currently has a census of six residents in care and three receiving hospice services. Residents were observed eating breakfast in the dining room.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits, The hot water temperature measured between 105.9 and 109.5 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational. The fire extinguisher is charged and was serviced on March 5, 2024. The facility’s last fire drill was conducted on November 30, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA also observed the First Aid Kit had the required elements and a First Aid book.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a pending renewal administrator certificate which expires on December 2, 2026..

(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TESSA'S PLACE 3
FACILITY NUMBER: 306005910
VISIT DATE: 01/10/2025
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(Continued from LIC 809)

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Mark Cruz, Administrator (AD) and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
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