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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602179
Report Date: 05/19/2025
Date Signed: 05/19/2025 11:04:41 AM

Document Has Been Signed on 05/19/2025 11:04 AM - 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:
05/19/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Victoria Legaspi, LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit for a Plan of Correction (POC) clearance. LPA Lopez identified herself and was granted entry by Licensee Victoria Legaspi. LPA met with Licensee Legaspi and discussed the purpose of today’s visit.

On 4/24/25, the Licensee was issued multiple deficiencies regarding staff training, residents' functional capabilities assessments, residents' pending medical assessments, activities for residents, and facility financial records. At the time of the visit, California Code of Regulations (CCR), Sections 87506 Resident Records, 87456 Evaluation of Suitability for Admission, 87464 Basic Services, 87213 Finances, and Health and Safety Code (HSC), Section 1569.267 Resident’s Bill of Rights, were discussed with the Licensee. A POC was jointly developed with Licensee Legaspi and the deficiencies issued were due between 05/09/2025 through 05/15/2025.

During today’s visit, LPA requested copies of their POCs for five (5) of the deficient practice statements that were jointly developed, but they were unable to be produced by the Licensee. A failure to correct was issued for each of the deficiencies on the time elapsed, between the due dates of 5/9/25 through 5/15/25.

On 04/17/25, Licensee was issued a deficiency for CCR, Section 87211 Reporting Requirements, due 5/02/25. The licensee was unable to produce the POC, and this deficiency will be reissued and recited during today’s visit.

Also, on 04/17/2025, the Licensee was issued a Type A deficiency regarding false/misleading statements. At that time, CCR, Section 87207, was discussed with Licensee Legaspi. A POC was jointly developed with Licensee Legaspi with a due date of 4/18/25. On 4/24/25, Licensee was unable to produce the POC to clear the deficiency, and a failure to correct was issued for the time elapsed, between 4/18/25 through 4/24/25.

(Continuation on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/19/2025
NARRATIVE
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(Continuation of LIC809)

During today’s visit, the Licensee was still unable to produce the POC, and a failure to correct was issued for the continued deficiency.

On 04/02/25, Licensee was issued deficiencies for CCR, Sections 87355 Criminal Record Clearance, 87208 Plan of Operations, HSC Sections 1569.605 Liability Insurance, and Section 1669.15 License application. During today’s visit, Section 87208 is being recited and may be reviewed on the LIC809-D page of this report.

On 12/05/2024 and 12/06/2024, the Licensee was issued civil penalties for a visit conducted on 10/28/24, for a total of 6 deficiencies for Personnel Records, Resident Records, Medical Assessments, and Reappraisals. During today's visit, the licensee cleared two citations for resident records, specifically admission agreement, and physician's report, specifically TB test, but will be issued civil penalties until 5/18/25 as it has cleared on 5/19/25. Licensee was issued additional civil penalties as the deficiencies issued on 12/05/2024 and 12/06/2024 have yet to be corrected. Two deficiencies were cleared during today’s visit for citations issued on 10/28/24.

An exit interview was conducted, and a copy of this report, along with Licensee Rights (LIC 9058 03/22), and civil penalties issues were provided to Licensee Victoria Legaspi at the conclusion of the visit (via email to the email on file). The signature below confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/19/2025 11:04 AM - It Cannot Be Edited


Created By: Carmen Lopez On 05/19/2025 at 09:23 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: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2025
Section Cited
CCR
87208(a)(7)(B)

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87208 Plan of Operation (a)(7)(B) The licensee shall… operate the facility in accordance with the… plan of operation… Any significant changes… shall be submitted to the licensing agency for approval... This requirement was not met as evidenced by:
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Licensee agreed to submit an updated plan of operation, including but not limited to: a new facility sketch (LIC999), Personnel Report (LIC 500), and updates to ensure compliance with regulations effective January 1, 2025, by the due date, May 26, 2025.
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Based on observation and interview, the Licensee changed the use of facility space and did not submit the updated plan to the Department for approval.
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Type B
05/26/2025
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident… This requirement is not met as evidenced by:
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Licensee agreed to submit an incident report for the incident that transpired with residents R2 and R3 by the POC due date, May 26, 2025.
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 incident were not reported regarding the residents, which posed a potential personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
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