<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424403
Report Date: 09/17/2024
Date Signed: 09/27/2024 05:06:37 PM

Document Has Been Signed on 09/27/2024 05:06 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TENDER LOVING CAREFACILITY NUMBER:
336424403
ADMINISTRATOR/
DIRECTOR:		KENYATIE SHAW-HOWARDFACILITY TYPE:
735
ADDRESS:1125 SILVERCREEKTELEPHONE:
(951) 339-3028
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: 3DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:19 PM
MET WITH:John BulterTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Mary Rico and Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs were granted entry to the facility. The facility is a five (5) bedroom, four (4), bathroom home and, with a kitchen/dining area, living room and attached garage. Licensed capacity is (6) current census (3). LPAs were accompanied by John Bulter to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked. There was a designated space for client/staff files.

During facility tour LPAs observed the first and second floor carpet to be dirty. LPAs observed ants inside the kitchen cabin and inside the upstairs bathroom. In addition, the outdoor patio chairs were observed to be ripped. Licensee stated they will be replacing the patio chairs. Furthermore, during record review. Licensee stated they did not have an Infection Control Plan. The Licensee did not allow LPAs to enter the Master bedroom and bedroom number 4. Licensee stated that the Master bedroom and bedroom number 4 are staff bedrooms. Community Care Licensing are required to inspect all rooms.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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 6
Document Has Been Signed on 09/27/2024 05:06 PM - It Cannot Be Edited


Created By: Mary Rico On 09/17/2024 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TENDER LOVING CARE
FACILITY NUMBER: 336424403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5
85095.5 Infection Control Requirements

(c) An infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review the licensee did not comply with the section cited above by not having an Infection Control Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
1
2
3
4
Licensee stated they will create and Infection Control Plan for the facility and send a copy to LPA Rico
Type B
Section Cited
CCR
80087(a)
80097(a) Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having the carpet dirty in the first and second floor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
1
2
3
4
Licensee stated they will clean the carpet and send proof to LPA
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/27/2024 05:06 PM - It Cannot Be Edited


Created By: Mary Rico On 09/17/2024 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TENDER LOVING CARE
FACILITY NUMBER: 336424403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)(1)

80087(a)(1) Buildings and Grounds

The licensee shall take measures to keep the facility of files and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation , the licensee did not comply with the section cited above by having ants inside the kitchen cabin and upstairs bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2024
Plan of Correction
1
2
3
4
Licensee has agreed to clean the kitchen cabin and upstairs bathroom. Licensee stated they will send proof to LPA Rico
Type A
Section Cited
CCR
80044(a)
80044(a) Inspection Authority of the Licensing Agency

The licensing agency shall have the inspection authority specified in Healh and Safety Code Sections 1526.5,1533,1534 and 1538.7

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview the licensee did not comply with the section cited above by not allowing LPA Rico and LPA Hernandez to enter two bedrooms upstairs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
1
2
3
4
Licensee stated to submit Statement of Understanding to California Code of Regulations (CCR) 8044(a) to LPA Rico and will provide access to Community Care Licensing Department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/27/2024 05:06 PM - It Cannot Be Edited


Created By: Mary Rico On 09/17/2024 at 02:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TENDER LOVING CARE
FACILITY NUMBER: 336424403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)(1)
80069(b)(1) Client Medical Assessments

The assessment shal be performed by a licensed physician or designee, who is also licensed professional and the assessment shall not be more than one year old when obtained

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above in 3 out of the 3 clients did not have an updated medical assessment for the year 2024. 3 out of the 3 clients medical assessment was from the year 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
1
2
3
4
Licensee stated they will obtain an updated medical assessment for the year 2024 for the three clients.
Type B
Section Cited
CCR
85087.2(b)
85087.2(b) Outdoor Activity Space

The outdoor activity area shall provide a shaded area, and shall be comfortable and furnished for outdoor use

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation , the licensee did not comply with the section cited above by having ripped patio chairs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
1
2
3
4
Licensee stated they will be replacing clients outdoor patio chairs.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/27/2024 05:06 PM - It Cannot Be Edited


Created By: Mary Rico On 09/17/2024 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TENDER LOVING CARE
FACILITY NUMBER: 336424403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023
80023(b) Disaster and Mass Casualty Plan

Disaster drills shall be conducted at least every six months

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onrecord review, the licensee did not comply with the section cited above by not conducting drills every six months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
1
2
3
4
Licensee stated they will submit Statement of Understanding to California Code of Regulation 80023(b) and will send a copy to LPA Rico. Licensee also stated they will be conducting disater drills for the month of September and will send a copy to LPA Rico
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TENDER LOVING CARE
FACILITY NUMBER: 336424403
VISIT DATE: 09/17/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. 3 out of the 3 clients did not have an updated medical assessment for the year 2024.LPA reviewed three (3) client medications. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, (7) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provide to John Bulter. Along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6