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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000467
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:33:11 PM

Document Has Been Signed on 10/30/2024 03:33 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TENDER CARE IIFACILITY NUMBER:
306000467
ADMINISTRATOR/
DIRECTOR:
LOAN KIM TO AND HAI LUFACILITY TYPE:
740
ADDRESS:24661 KIM CIRCLETELEPHONE:
(949) 455-1677
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Leah Ann FajardoTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with staff member Armida Santos and explained the reason for the visit. The facility is a one story home with 4 bedrooms, 2 shared and 2 private, staff room, 2 bathrooms, staff room, living room, dining room, family room, kitchen and an attached 2 car garage. Facility is licensed for a capacity of 6 non-ambulatory residents with a hospice waiver for 5. LPA observed the See Something, Say Something poster (PUB 475) posted on the wall. The Administrator, Leah Ann Fajardo's Administrator's Certificate expires on March 10, 2025. LPA and staff toured the facility. LPA observed all resident rooms had the required furnishings and bed linens. LPA observed both bathrooms are clean and operational. The living room has a sofa, 4 recliner chairs and a large screen TV. LPA observed the fireplace in the family room is screened. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Knives are kept locked under the kitchen sink. The fire extinguisher in the kitchen is fully charged. LPA observed the medication is kept locked in the stand alone cabinet next to the kitchen. LPA observed both bathrooms are clean and operational. Hot water measured 111.9 degrees Fahrenheit in both bathrooms. LPA toured the backyard. No bodies of water observed. There is a covered patio with a table and chairs. Both exit gates on each side of the house are operational. No hazards observed in the backyard. LPA toured the garage. The garage is kept locked and used for storage. LPA observed a 3 day emergency supply of food and water. LPA reviewed 5 resident records and medication. No discrepancies observed. LPA reviewed 2 staff files, no discrepancies observed. Both staff have the required training including CPR training. Both staff present at the facility (LPA reviewed their staff files) are background cleared and associated to the facility. Smoke detectors/carbon monoxide detectors tested operational. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
Sheila SantosTELEPHONE: (714) 334-2062
Joseph AlejandreTELEPHONE: 714-705-6018
DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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