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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602179
Report Date: 05/09/2023
Date Signed: 05/09/2023 12:56:59 PM

Document Has Been Signed on 05/09/2023 12:56 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
CCLD Regional Office, 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:
05/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Victoria Legaspi, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a complaint investigation and in conjunction conducted this Case Management visit. LPA Lopez identified herself and was granted entry by Victoria Legaspi, Administrator. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Victoria Legaspi, Administrator.

During the visit it was discovered there were two incidents which transpired at the facility one on March 2, 2023, for resident #1 (R1 - See LIC811 Confidential Names list) and second incident transpired on April 28, 2023, for resident #2 (R2 – see LIC811 Confidential Names List) and needed to be reported to the Department. During today’s visit, LPA toured the facility, briefly spoke with staff and residents, and requested and obtained resident records. LPA did obtain a copy of the incident reports while at the facility.

Two technical advisories and one deficiency were given per Title 22, Division 6, Chapter 8 of the California Code of Regulations (see LIC9102 and LIC809-D). This report was discussed, and an exit interview was conducted with Victoria Legaspi, Administrator, to whom a copy of this report, Confidential Names list (LIC811), and the Licensee appeal Rights (LIC9058) were provided via email. An electronic email receipt confirms the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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Document Has Been Signed on 05/09/2023 12:56 PM - It Cannot Be Edited


Created By: Carmen Lopez On 05/09/2023 at 11:16 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: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2023
Section Cited
CCR
87355(b)

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87355 (b) Criminal Record Clearance Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. … this requirement was not met as evidence by:
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Administrator made an appointment for the individual to have fingerprints conducted for background clearance. Appointment was made for 5/9/23. A confirmation receipt will be submitted to LPA by POC due date 5/10/23.
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Based on interviews with staff and Administrator, Staff #1 (S1) did not have a background clearance. This posed a potential safety risk to 4 of 4 residents (R3, R4, R5, and R6) 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.
SUPERVISOR'S NAME:Rebecca Hedgecock
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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