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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602179
Report Date: 10/18/2023
Date Signed: 10/18/2023 02:23:20 PM


Document Has Been Signed on 10/18/2023 02:23 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 HOMEFACILITY NUMBER:
374602179
ADMINISTRATOR:VICTORIA S. LEGASPIFACILITY TYPE:
740
ADDRESS:1430 SHERYL LNTELEPHONE:
(619) 399-3552
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:6CENSUS: 4DATE:
10/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Victoria Legaspi, LicenseeTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. 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 clients at any given time at the facility site. During today’s inspection, the facility’s current census was four (4) residents living at the facility; of whom 4 were present at the facility site during the inspection.

LPA, accompanied by the Licensee, toured the interior and exterior sections of the facility, and inspected each room. The facility needed to be cleaned and sanitized but was 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, but needed to be sanitized. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present.

Due to unforeseen circumstances of the facility grounds and staff and resident documentation, an annual continuation was determined during the visit.

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 Insurance Certificate, Designation of Administrative Responsibility LIC 308, 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 copy of Licensee’s Administrator Certificate will be submitted to LPA by 11/01/23
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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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