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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204739
Report Date: 04/30/2025
Date Signed: 04/30/2025 04:50:27 PM

Document Has Been Signed on 04/30/2025 04:50 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:TLC GUEST HOME 1FACILITY NUMBER:
198204739
ADMINISTRATOR/
DIRECTOR:		TERESITA L. CASTANEDAFACILITY TYPE:
740
ADDRESS:18309 FAIRVIEW LANETELEPHONE:
(310) 819-3965
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
04/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Cristina StoDomingoTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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On 04/30/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Caregiver, Cristina StoDomingo, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed for 6 non-ambulatory residents over the age of 60, with a hospice waiver for 6 residents. Currently six (6) residents reside at the facility, and all six (6) were present during the visit.

Physical Plant/Structure The facility is a single-story home in a residential neighborhood. The facility consists of six (6) resident bedrooms, five (5) bathrooms, staff office, living room, dining room, kitchen, and garage. LPA inspected the inside and outside of the facility. The front yard was observed to be landscaped and well maintained. The backyard has a covered patio with a large table and chairs to accommodate all residents. An additional table and chair are under the shade of a tree. The backyard is landscaped and well maintained. LPA observed all walkways around the home to be clean, clear, and free of debris, obstructions, and hazards. LPA did not observe any bodies of water on the premises.

Eva M AlvarezTELEPHONE: (323) 981-1755
Wendy GibbsTELEPHONE: (323) 981-1755
DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TLC GUEST HOME 1
FACILITY NUMBER: 198204739
VISIT DATE: 04/30/2025
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Bedrooms LPA inspected all bedrooms and observed them to be clean and in good repair. All bedrooms had the required furniture including a bed, dresser, nightstand, chair, storage space for personal belongings, and ample lighting. All beds were observed to have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed and ample supply of linens in a cabinet in the hallway.
Bathrooms LPA inspected all bathrooms and found them to be clean and operational. All showers were observed to be clean and free of mildew and mold. All showers had a nonskid mat, shower chairs, and secured safety handrails. LPA observed an ample supply of hygiene products and incontinent care products for residents. LPA observed an ample supply of towels, hand towels and wash cloths in the cabinet in the hallway. The water temperature in the bathrooms measured 116.3-degrees, 117.4-degrees, 117.7-degrees, 118.3-degrees and 118.4-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed all appliances to be in good repair and operational. LPA observed a 3-day supply of perishable foods, and a 7-day supply of nonperishable foods properly packaged, labeled, and dated. LPA observed an additional supply of foods in the refrigerators in the garage. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed all knives and sharps secured in a locked drawer in the kitchen and are inaccessible to residents. LPA observed all cleaning supplies secured in a locked cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 116.7-degrees Fahrenheit.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TLC GUEST HOME 1
FACILITY NUMBER: 198204739
VISIT DATE: 04/30/2025
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Common Rooms LPA observed a couch and recliners in the living room, to accommodate residents. LPA observed books, magazines, games, and activities in the living room. The dining room has a long rectangular table with chairs to accommodate all residents. LPA observed all rooms to have ample lighting. All walkways and hallways in the facility were observed to be clean, clear, and free of obstructions and hazards.
Safety LPA observed a fully charged fire extinguisher in the kitchen that was last serviced on 04/29/25. All smoke and carbon monoxide detectors are operable. The facility’s last inspection by the Torrance Fire Department was on 07/23/24. LPA observed all exits clearly marked. The last emergency drill was conducted on 03/05/25. LPA inspected the First Aid kit and observed it contained the required items and a manual. The facility has a working landline telephone. The facility sketch is posted in the dining room. LPA observed all required documents including emergency numbers and the facilities Emergency and Disaster Plan posted in the facility. When doors leading to the outside of the facility are opened an audio signal is produced. There are no security bars over the windows. There are no firearms or ammunition stored on the premises.
File Review LPA reviewed six (6) resident files and found they contained the required documents. LPA reviewed the files for the administrator and three (3) staff files and found they contained the required documents, certification, and training. The Administrator Certificate is valid till 09/17/25. LPA informed staff the facility’s Licensing Fees are due on 05/07/25. LPA provided staff with the amount owed and the PIN for online payment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TLC GUEST HOME 1
FACILITY NUMBER: 198204739
VISIT DATE: 04/30/2025
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Medications LPA observed medications secured in a locked cabinet in the dining room and are inaccessible to residents. LPA observed all medications to be in their original packaging. LPA reviewed residents Medication Administration Records (MARs) and medications for all residents. LPA observed six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records.
Infection Control LPA observed a sanitizing station at the entrance at the facility. It has a visitor log, hand sanitizer, masks and a thermometer. LPA observed infection control signs posted throughout the facility. LPA observed a 120-day supply of Personal Protective Equipment (PPE) stored in the garage. LPA observed an ample supplies of hand soap, paper towels, and cleaning supplies stored in the garage.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe or cite any deficiencies during today’s visit.

An exit interview was conducted with Caregiver, Edilberto Bernardino, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5