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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602179
Report Date: 03/19/2024
Date Signed: 03/19/2024 04:09:29 PM

Document Has Been Signed on 03/19/2024 04:09 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: 5DATE:
03/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Victoria Legaspi, LicenseeTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit for a Plan of Correction clearance and in conjunction conducted a health and safety check for clients in care. LPA Lopez identified herself and was granted entry by Licensee Victoria Legaspi. LPA met with Licensee Legaspi and discussed the purpose of the visit.

On 11/01/23, the facility was issued four deficiencies regarding updated Insurance information, updated CPR training, updated Administrator’s Certificate, and the kitchen being unsanitary and free from rodents and vermin.

During today’s visit, LPA inspected the kitchen area and observed that the facility was free from insects and vermin. Licensee had made a contract with a pest control company who renders services to the facility every three months. Licensee provided LPA with their invoices. As such, this deficiency is deemed to be cleared and corrected.

Per Licensee Legaspi, the other deficiencies are pending. Based on the information obtained and review of the annual inspection, the facility is being recited during today’s inspection and citations may be reviewed on the attached LIC809-D page of this report.

An exit interview was conducted, a plan of correction was jointly developed, and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee Legaspi at the conclusion of the visit. The signature below confirms receipt of these documents.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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 3
Document Has Been Signed on 03/19/2024 04:09 PM - It Cannot Be Edited


Created By: Carmen Lopez On 03/19/2024 at 03:24 PM
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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2024
Section Cited
HSC
1569.605

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On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
This requirement is not met as evidenced by:
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Licensee will obtain liability insurance for the facility and submit a copy of their insurance to LPA by POC due date, 4/01/24.
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Based on Licensee interview and record review of the facility file, the licensee did not comply with the section cited above for 5 out of 5 residents in care which posed a potential safety risk to persons in care.
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Type B
04/01/2024
Section Cited
HSC1569.618(c)(3)

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(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
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Licensee will make an appointment to obtain their CPR and first aid training. Licensee will submit a copy of their CPR/First Aid training to LPA by POC due date, 4/01/24.
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Based on record review of the Licensee's CPR/First Aid certification, the licensee did not comply with the section cited above for 5 out of 5 residents which posed a potential safety 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.
SUPERVISOR'S NAME:Jennifer Lott
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/19/2024 04:09 PM - It Cannot Be Edited


Created By: Carmen Lopez On 03/19/2024 at 03:28 PM
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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2024
Section Cited
CCR
87412(d)

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(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:
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Licensee will be submitting payment to the Department as a last step to receive their certificate and submit a copy of their payment to LPA by POC due date, 4/01/24. Once Licensee receives their Administrator's Certificate they will submit a copy to LPA.
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Based on Licensee interview and record review of the Administrator's Certificate, the licensee did not comply with the section cited above for 5 out of 5 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.
SUPERVISOR'S NAME:Jennifer Lott
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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