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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000467
Report Date: 10/10/2022
Date Signed: 10/10/2022 11:13:51 AM


Document Has Been Signed on 10/10/2022 11:13 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
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:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Armida Del RosarioTIME COMPLETED:
11:25 AM
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On 10/10/2022 at 9:38am, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Tender Care II. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on Infection Control. At 9:40am, LPA Cho met with Caregiver Joseph Santos in front of the facility and stated the purpose of the visit. LPA was allowed entry and completed the Coronavirus 2019 (COVID-19) screening procedure with Caregiver Armida Del Rosario. Caregiver Joshua Salvador was also present during today's visit. At 9:44am, Caregiver Santos contacted Licensee/Administrator (Admin) Loan Kim To and handed the phone to LPA. LPA spoke to Admin and stated the purpose of the visit. Admin gave consent for Caregiver Del Rosario to assist with the tour and sign the report on her behalf. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. LPA observed the Complaint Poster in the size of 8.5"x11" posted on the bulletin board which did not meet the Department size requirement of 20"x26." The facility is licensed for six non-ambulatory residents and has a hospice waiver for five. There are currently six residents living in the facility of which three are in hospice care.

At 9:54am, LPA Cho conducted a tour of the physical plant along with Caregiver Armida Del Rosario. The single story home consists of four resident bedrooms and two bathrooms. There is one staff bedroom. The facility also has a formal living room, family room, dining area, kitchen, and an attached two-car garage with a laundry area. The resident bedrooms had the required furnishings. Resident bathrooms were checked. Toilets and water faucets worked properly, showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in both bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 106.5 degrees Fahrenheit in the Bathroom #1 and 105.9 degrees Fahrenheit in Bathroom #2. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TENDER CARE II
FACILITY NUMBER: 306000467
VISIT DATE: 10/10/2022
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The fire extinguisher was mounted and fully charged but was last purchased on 06/30/2021. The smoke/carbon monoxide detectors were tested and operational along with the auditory devices. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No bodies of water were present, and there was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. The exit side gate was self-closing and self-latching. There were inadequate supply of emergency food and water, and sufficient supply of PPEs.

At 10:41am, LPA provided the following guidance to Administrator Loan Kim To via a telephone call: to continue taking temperature for residents and staff, to maintain a sufficient supply of emergency food and water, to obtain or service the fire extinguisher, and to enlarge the Complaint Poster to 20"x26."

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit. An exit interview was conducted with Caregiver Armida Del Rosario, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022
LIC809 (FAS) - (06/04)
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