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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602179
Report Date: 03/20/2023
Date Signed: 03/20/2023 10:15:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/24/2022 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20221024162057
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: 6DATE:
03/20/2023
UNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Victoria Legaspi, LicenseeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Lack of supervision resulting in a resident AWOL.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the finding in the above mention complaint allegation. LPA identified herself and discussed the purpose of the visit with Licensee Victoria Legaspi.

On 10/24/22, Community Care Licensing (CCL) received a complaint alleging lack of supervision resulting in a resident AWOL.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff and outside sources. Based on Resident 1’s (R1) (Please see LIC811 confidential names list) Physician’s Report dated 03/01/23, R1 was deemed to not require continuous care, and had no cognitive deficits. In addition, R1’s Individual Care Plan dated 3/16/22, revealed R1 was

(Continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 08-AS-20221024162057
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TENDER LOVING CARE GUEST HOME
FACILITY NUMBER: 374602179
VISIT DATE: 03/20/2023
NARRATIVE
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independent with dressing, eating and ambulatory without an assisted device. R1 was found by outside source 1 (OS1) and R1 was unable to communicate with OS1 due to language barrier. OS1 sought out communication services and was then able to communicate with R1. During the time frame of the report, R1 was able to leave the facility unassisted.

Based on LPA's interviews with staff, outside source interviews, and record reviewed there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Licensee, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2