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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603627
Report Date: 10/11/2021
Date Signed: 10/12/2021 03:13:27 PM

Document Has Been Signed on 10/12/2021 03:13 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:TLC GUEST HOMEFACILITY NUMBER:
374603627
ADMINISTRATOR:HENRIETTA CHONGFACILITY TYPE:
735
ADDRESS:1639 MARL AVETELEPHONE:
(619) 241-9231
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Caregiver, Alita ReyesTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. LPA was greeted at the front entrance by Caregiver, Alita Reyes and granted entry after identifying herself. LPA Hamilton explained the purpose of the visit. This facility serves six (6) developmentally disabled adults ages 18 through 59 years; all of whom shall ambulatory.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Caregiver reviewed the facility’s COVID-19 Mitigation Plan. LPA observed one central entry point; routine symptom screening initiated at entry for staff, clients and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE and disinfectants. LPA discussed the Provider Information Notice (PIN) regarding updated guidance on visitation and moving the universal screening area to the front door.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Caregiver and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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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