374602179-11-1-2023-08-AS-CLOZ-CX6TVJ-20231101150401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602179
Report Date: 11/01/2023
Date Signed: 11/01/2023 03:05:01 PM

Document Has Been Signed on 11/01/2023 03:05 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

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

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 Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection continuation. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Licensee Victoria Legaspi. LPA discussed the purpose of the visit with Licensee Legaspi. According to the facility’s license, there may be a maximum of six (6) non-ambulatory elderly residents at any given time at the facility site. During today’s inspection, the facility’s current census was three (3) residents living at the facility; of whom 3 were present at the facility site during the inspection. LPA, accompanied by the Licensee, toured the interior sections of the facility, and inspected each room. The facility was cleaned and sanitized and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. There were at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in a locked area. No pools or bodies of water on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors and facility telephone were all in working condition. Fire extinguisher(s) were present. First aid kit and handbook were complete and readily accessible. Required licensing postings were observed in a visible area of the facility. [CONTINUED ON LIC 809-C]

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

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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TENDER LOVING CARE GUEST HOME	FACILITY NUMBER: 374602179
	VISIT DATE: 11/01/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

LPA interviewed residents, and reviewed resident records. During today’s visit there were 3 residents on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area.

There were deficiencies observed during today's annual inspection. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D.

The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Licensee Victoria Legaspi to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Licensee Legaspi to submit a current Personnel Report LIC 500, and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms available at www.ccld.ca.gov. A current Designation of Administrative Responsibility LIC 308 was submitted to the licensing office.

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

LIC809 (FAS) - (06/04)

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