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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000467
Report Date: 10/19/2021
Date Signed: 10/19/2021 01:43:39 PM

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:TENDER CARE IIFACILITY NUMBER:
306000467
ADMINISTRATOR:LOAN KIM TO AND HAI LUFACILITY TYPE:
740
ADDRESS:24661 KIM CIRCLETELEPHONE:
(949) 455-1677
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 6DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Armida Del RosarioTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver. LPA met with Armida Del Rosario, caregiver and explained the nature of the visit.

LPA Martinez accompanied by caregiver began the tour of the inside and outside of the facility. There are six residents in care and no active covid-19 cases in the facility. LPA observed five residents having lunch in the dinning room and one resident in their bedroom. All residents appeared to be clean and well taken care of. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All bathrooms observed to have ample supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and they appeared to be clean and sanitized. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking temperature checks daily and documenting the results. LPA observed the emergency disaster and evacuation plan. Facility has supply of emergency food and water in the attached garage. Facility has PPE supply on hand and throughout the facility. LPA toured the outside of the facility and observed shaded seating area for resident’s enjoyment. Outdoor seating area is used for visitation as well. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit. LPA emailed the signed and approved plan to Kim Loan, Administrator for their records.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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