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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603627
Report Date: 06/16/2022
Date Signed: 06/16/2022 03:46:49 PM

Document Has Been Signed on 06/16/2022 03:46 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:
06/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Candy Chong, LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an announced Case Management visit for a Change in Ambulatory Status. LPA identified herself and was granted entry by Candy Chong, Licensee. LPA met with Licensee Chong and disclosed the purpose of the visit.

The facility has requested a change from 6 – ambulatory clients to 6 clients of whom 2 – ambulatory, 3 – non-ambulatory, and 1 - bedridden clients reside at the facility. A fire clearance was granted by the local fire authority on May 24, 2022 and received by Community Care Licensing (CCL) on June 7, 2022. During today's visit, LPA toured the facility, and observed clients in care. As of today, there are six (6) clients in care all of whom are ambulatory at this time.

During the tour of the facility, LPA observed each clients bedroom and bathroom. During the tour, LPA observed the physical plant and residents' accommodations including furnishings, linens and personal hygiene items; resident bathrooms are equipped with cleaning products; toxic substances are stored in a locked cabinet in the garage; medication storage and administration logs are located in a locked cabinet located in the kitchen area; sufficient space to conduct activities was present; facility posting requirements were present in a common area; the facility administrators certification was current; no pool or other body of water is present on the facility grounds; per the Administrator there are no guns, weapons or ammunition located on the property. No deficiencies were issued during this visit.

An exit interview was conducted with Candy Chong, Licensee. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided at the conclusion of the visit. The signature below serves as confirmation that the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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