Community Care Licensing

Document Has Been Signed on 11/01/2023 03:18 PM - It Cannot Be Edited

FACILITY NAME:	TENDER LOVING CARE GUEST HOME		FACILITY NUMBER:	374602179
ADMINISTRATOR:	VICTORIA S. LEGASPI		FACILITY TYPE:	740
ADDRESS:	1430 SHERYL LN		TELEPHONE:	(619) 399-3552
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY: 6		CENSUS: 3	DATE:	11/01/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Victoria Legaspi, Licensee		TIME COMPLETED:	03:15 PM

SUPERVISORS NAME: Denise Powell LICENSING EVALUATOR NAME: Carmen Lopez LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023

Link to Parent Document Below:

FACILITY NAME: TENDER LOVING CARE GUEST HOME	FACILITY NUMBER: 374602179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2023

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Licensee interview and record review of the facility file, the licensee did not comply with the section cited above for 3 out of 3 residents in care which posed a potential safety risk to persons in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	Licensee will be submitting a copy of the liability insurance to LPA by POC due date, 11/16/23.

Type B

Section Cited

HSC

1569.618(c)(3)

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of the Licensee's CPR/First Aid certification, the licensee did not comply with the section cited above for 3 out of 3 residents which posed a potential safety risk to persons in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	Licensee will submit a copy of their current CPR/First Aid certification to LPA by POC due date, 11/16/23.

SUPERVISOR'S NAME: Denise Powell LICENSING EVALUATOR NAME: Carmen Lopez LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023

Link to Parent Document Below:

FACILITY NAME: TENDER LOVING CARE GUEST HOME	FACILITY NUMBER: 374602179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2023

Type B

Section Cited

CCR

87412(d)

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Licensee interview and record review of the Administrator's Certificate, the licensee did not comply with the section cited above for 3 out of 3 residents which posed a potential personal rights risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Licensee will be submitting their Administrator's Certificate to LPA by POC due date of 11/10/23.

Type B

Section Cited

CCR

87555(b)(27)

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above for 3 out of 3 residents which posed a potential personal rights risk to persons in care.
	POC Due Date: 12/01/2023
	Plan of Correction
1 2 3 4	Licensee will contact a terminator and submit invoice(s) to LPA by POC due date, 12/01/23.

SUPERVISOR'S NAME: Denise Powell LICENSING EVALUATOR NAME: Carmen Lopez LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023