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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006097
Report Date: 03/15/2022
Date Signed: 03/15/2022 04:00:39 PM

Document Has Been Signed on 03/15/2022 04:00 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 4FACILITY NUMBER:
306006097
ADMINISTRATOR:AVENDANO, ELEONORFACILITY TYPE:
740
ADDRESS:2825 CALLE GUADALAJARATELEPHONE:
(949) 331-3822
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6CENSUS: 0DATE:
03/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Eleonor Avenado and Reiner AvenadoTIME COMPLETED:
03:43 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Eleonor Avenado and Administrator Reiner Avenado. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 10/22/2021 for a capacity of six non-ambulatory residents. Facility has a screening area in the entrance of the facility and LPA was screened upon entry. LPA observed covid signage at entrance to facility. LPA observed ample PPE supply.
LPA Lyman along with Licensee/ Administrators toured the facility at 2:05 PM and observed the following:
Structure: Facility is a one story, 6 bedroom, 4 bathroom house with an attached garage and a tan exterior. The exit gates are closed and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be single occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has multiple secured areas for toxins and sharps. Water Temperature: Tested and recorded between 114.0 and 117.1 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water as well as a posted emergency disaster plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Medication to be stored and locked in a locked cabinet in the entrance to facility. Facility to use a medication administration record. CONTINUED ON LIC 809C DATED 1/25/2021
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 4
FACILITY NUMBER: 306006097
VISIT DATE: 03/15/2022
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Resident & Staff File: Records to be are stored in a file cabinet in the dining room. Reading Material, Games, and Equipment: LPA observed activities such as coloring and games. Backyard: LPA observed a clean backyard with ample shaded seating for residents. Fire Clearance: Approved for six non-ambulatory residents on 11/09/21.

During the visit, LPA observed the following:
  • There is a cracked tile in "Jack and Jill" restroom. Licensee to repair tile on 03/16/22 and forward proof to LPA.
  • Facility does not have ample bath towels. Please maintain an ample supply of bath towels on-site.


Component III waived during the visit. Licensee is currently licensed for other facilities. Facility is ready to be licensed.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC809 (FAS) - (06/04)
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