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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424403
Report Date: 09/30/2024
Date Signed: 09/30/2024 03:02:39 PM

Document Has Been Signed on 09/30/2024 03:02 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: 4DATE:
09/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:John BulterTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mary Rico and Eldin Serrano conducted an unannounced visit to the facility to verify clearance of Plan of Correction from visit on 09/17/2024. LPA Rico and Serrano met with Administrator John Bulter.

The following Plan of Correction (POC)s were cleared at the time of the visit:


The Licensee was cited on 09/17/2024 for 80097(a) Buildings and Grounds. During today's visit LPAs conducted a facility tour, the carpet was observed to be cleaned. Therefore, the POC was cleared at today’s visit.

The Licensee was cited on 9/17/2024 for 80069(b)(1) Client Medical Assessments. During today’s visit, the Licensee provided verification all three clients have a Physical Appointment on October 14, 2024. to obtain Medical Assessment. Therefore, the POC was cleared at today’s visit.

The Licensee was cited on 9/17/2024 for 80087(a)(1) Building and Grounds. During visit LPAs conducted a facility tour, the kitchen cabins were observed to be clean and free from insects. Therefore, the POC was cleared at today’s visit.

The Licensee was cited on 9/17/2024 for 80044(a) Inspection Authority of the Licensing Agency. During visit LPAs conducted a facility tour, the licensee allowed LPAs to enter the two upstairs bedroom. Therefore, the POC was cleared at today’s visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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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: 09/30/2024
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The following deficiency were not cleared during the time of the visit:

The Licensee was cited on 09/17/2024 for 85087.2(b) Outdoor Activity Space. During today's visit and based on facility tour and interview, LPA Rico and LPA Serrano observed that the outdoor patio chairs were not replaced. The Plan of Correction was to replace the outdoor patio chairs. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days.

An exit interview was conducted with Administrator John Butler where this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided.

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

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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