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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602179
Report Date: 10/28/2024
Date Signed: 10/28/2024 05:08:33 PM

Document Has Been Signed on 10/28/2024 05:08 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/
DIRECTOR:		VICTORIA S. LEGASPIFACILITY TYPE:
740
ADDRESS:1430 SHERYL LNTELEPHONE:
(619) 399-3552
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 6CENSUS: 4DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Licensee Victoria LegaspiTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Licensee Victoria Legaspi. According to the facility’s license, the facility is licensed for six (6) non-ambulatory clients. There was a total of four (4) residents in care.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each client bedroom. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present. Hot water temperature was in compliance.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on premises.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher and first aid kit present. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff/client files. Staff files were not available for LPA review. Client files did not contain all required documents.

Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Licensee, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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 4
Document Has Been Signed on 10/28/2024 05:08 PM - It Cannot Be Edited


Created By: Alyssa Ramirez On 10/28/2024 at 10:06 AM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TENDER LOVING CARE GUEST HOME
FACILITY NUMBER: 374602179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above in 3 out of 3 staff ( S1, S2 &S3) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee will ensure that staff files are completed and will notify LPA when staff files are complete by POC due date. LPA will conduct visit to ensure that requirement has been met.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(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
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 1 staff (S1) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee will ensure that administartor fees are paid by POC due date so that administrator certificate can be processed. Licensee will email LPA receipt of payment by POC due date.
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:Robyn Clark
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/28/2024 05:08 PM - It Cannot Be Edited


Created By: Alyssa Ramirez On 10/28/2024 at 10:10 AM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TENDER LOVING CARE GUEST HOME
FACILITY NUMBER: 374602179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview & record review, the licensee did not comply with the section cited above in 2 out of 4 residents (R1 & R2) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee will ensure that residents have completed admissions agreement by POC due date and will notify LPA of completion. LPA will conduct visit to ensure that requirement has been met.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview & record review, the licensee did not comply with the section cited above in 1 out of 4 residents (R2) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee will ensure that resident has completed physican's report by POC due date and will notify LPA of completion. LPA will conduct visit to ensure that requirement has been met.
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:Robyn Clark
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/28/2024 05:08 PM - It Cannot Be Edited


Created By: Alyssa Ramirez On 10/28/2024 at 10:10 AM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TENDER LOVING CARE GUEST HOME
FACILITY NUMBER: 374602179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview & record review, the licensee did not comply with the section cited above in 1 out of 4 residents (R2) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee will ensure that resident has a TB test by POC due date and will notify LPA of completion. LPA will conduct visit to ensure that requirement has been met.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview & record review, the licensee did not comply with the section cited above in 4 out of 4 residents (R1, R2, R3 & R4) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee will ensure that residents have appraisals documented by POC due date and will notify LPA upon completion. LPA will conduct visit to ensure that requirement has been met.
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:Robyn Clark
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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