374603627-10-20-2023-08-AS-SMAZ-CWSSPW-20231020140349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603627
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:03:56 PM

Document Has Been Signed on 10/20/2023 02:03 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:	TLC GUEST HOME		FACILITY NUMBER:	374603627
ADMINISTRATOR:	HENRIETTA CHONG		FACILITY TYPE:	735
ADDRESS:	1639 MARL AVE		TELEPHONE:	(619) 241-9231
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY: 6		CENSUS: 6	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Administrator Henrietta Chong and Caregiver Alita Reyes		TIME COMPLETED:	02:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection visit. The facility file was reviewed prior to the visit. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Alita Reyes. Administrator Henrietta Chong arrived during the visit and assisted with the visit.

The facility was approved for six (6) clients, of which three (3) can be non-ambulatory. During today’s inspection there was six (6) clients in care. Five (5) clients were at day program and one (1) client was at the facility.

The LPA toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Personal Protective Equipment, including gloves, hand sanitizer, gowns and face shields were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked area.

No pools or bodies of water on the premises. Per administrator, no firearms or ammunition were kept at the facility. Carbon monoxide detectors, and Fire extinguisher were present. A First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

(See LIC 809C for continuation of report.)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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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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: TLC GUEST HOME	FACILITY NUMBER: 374603627
	VISIT DATE: 10/20/2023

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The LPA conducted interviews and reviewed client and staff files. The files revealed facility staff did not have first aid training. This deficiency was cited in accordance with California Code of Regulations, Title 22, and cited in an LIC 809D. A plan of correction was jointly formulated with the administrator.

An exit interview was conducted with Chong, to whom a copy of this report, LIC 809D, and the Licensee/Appeal Rights (LIC 9058), were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/20/2023 02:03 PM - It Cannot Be Edited

Created By: Sabel Martinez On 10/20/2023 at 01:32 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: TLC GUEST HOME	FACILITY NUMBER: 374603627
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not ensure staff were trained in first aid, which posed a potential health, safety or personal rights risk to 6 of 6 persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have all staff first aid trained and submit proof, by 10/27/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Sabel Martinez

LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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