<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603627
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:56:35 PM

Document Has Been Signed on 10/30/2024 05:56 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:TLC GUEST HOMEFACILITY NUMBER:
374603627
ADMINISTRATOR/
DIRECTOR:		HENRIETTA CHONGFACILITY TYPE:
735
ADDRESS:1639 MARL AVETELEPHONE:
(619) 241-9231
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Caregiver Alita Reyes and Administrator Henrietta "Candy" ChongTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dang Nguyen and Licensing Program Manager (LPM) Robyn Clark conducted an unannounced visit to conduct a Required Annual Inspection. LPA and LPM were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Alita Reyes. LPA and LPM then met with Licensee Henrietta "Candy" Chong, who arrived later during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, of which all may be ambulatory, three (3) may be non-ambulatory, and one (1) may be bedridden. Per LIC602 Physician’s Reports, staff interviews, and LPA/LPM observation: During today’s inspection, there were a total of six (6) clients in care, and all were ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During today’s visit, LPA and LPM performed a welfare check on all clients in care, interviewed multiple facility staff and clients, and reviewed records for all clients and active staff. LPA and LPM, accompanied by the Licensee, also toured the interior and exterior of the facility, and inspected all common areas and resident bedrooms. During the inspection, the Department observed these hazardous items in areas that were accessible to clients: two (2) sharp cooking knives, two (2) cans of paint, two (2) small bottles of cleaning chemicals, one (1) container of disinfecting wipes, and one (1) bottle of 91% isopropyl rubbing alcohol. [These items were handed to staff and locked away during today’s visit.]

The facility was in good repair and bedrooms and common areas were mostly clean, except for Bedroom #2 [occupied by Client #1 (C1) and Client #2 (C2)], where two (2) spider cobwebs (each over one foot long) were observed on a wall and ceiling, and a three-dimensional build-up of dust was observed on the window blinds and ceiling fan. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The cobwebs and dust were cleaned up during today's visit. Three (3) trash cans did not have tight-fitting covers, as required. [CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TLC GUEST HOME
FACILITY NUMBER: 374603627
VISIT DATE: 10/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809] Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

The facility’s ambient internal temperature was complaint at 73 F. Hot water temperature at taps accessible to clients were initially too cold, per regulation: Kitchen Sink was 88.2 F, Bathroom #1 Sink was 85.5 F, Bathroom #2 Sink was 87.4 F, and Bathroom #3 Sink was 86.5. [During today’s visit, adjustments were made to the facility’s water heater to bring these taps back into the required temperature range.] Appliances to preserve perishable food were compliant in temperature: Both refrigerators were 40 F, and both freezers were 0 F. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored.

There were no fireplaces or open-faced heaters accessible to clients. No pools or bodies of water were observed on the premises. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition are kept at the facility. Fire detection system, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months.

Training records showed that staff had received training on both Personal Protective Equipment (PPE) and the facility’s written Emergency Disaster Plan within the last year, as required. Reserve supplies of PPE were on site. Licensee did not have proof that the administrator met training requirements regarding Human Immunodeficiency Virus (HIV) and Tuberculosis (TB) within the last two (2) years, as required. Fire/disaster drills were performed at required intervals. Required licensing postings were observed in visible areas of the facility. Licensee presented proof of current business liability insurance.

Five (5) deficiencies were cited per California Code of Regulations, Title 22 (refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA and LPM also issued one Technical Violation (TV) regarding staff training on inhaler devices (refer to the LIC9102-TV page).

An exit interview was conducted with Licensee Chong, to whom a copy of this report, the LIC 809-D pages, the LIC 9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/30/2024 05:56 PM - It Cannot Be Edited


Created By: Dang Nguyen On 10/30/2024 at 05:01 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and LPM observation, Licensee did not ensure that cleaning solutions, poisons, and other items that could pose a danger if readily available to clients were stored where inaccessible to clients. This posed an immediate health and safety risk to 6 of 6 clients (Client #1 through Client #6) in care.
POC Due Date: 10/30/2024
Plan of Correction
1
2
3
4
During today's visit, the cleaning solutions, paint, and sharp cooking knives, which were the basis for this deficiency, were handed to Licensee to lock away. This resolved the immediate risk. Licensee agreed to conduct retraining with its direct care staff on items which could pose a hazard to clients, and to E-mail the training sign-in sheet to LPA, by the 11/30/2024.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/30/2024 05:56 PM - It Cannot Be Edited


Created By: Dang Nguyen On 10/30/2024 at 05:01 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(2)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window coverings in client care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and LPM observation, in a bedroom where 2 of 6 clients (C1 and C2) resided, Licensee did not ensure that walls and window coverings were dusted or cleaned to ensure that they were not visibly contaminated or soiled. This posed a potential health and personal rights risk to persons in care.
POC Due Date: 11/30/2024
Plan of Correction
1
2
3
4
During today's visit, Licensee's staff cleaned the walls and celing to remove the cobwebs. They also cleaned the window blinds and ceiling fan to remove the dust. Licensee agreed to conduct retraining with its direct care staff on expectations around housekeeping in client bedrooms and common areas, and to submit the training sign-in sheet to LPA, by the POC due date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on measurement via thermometer, Licensee did not maintain hot water temperature controls to automatically regulate the temperature of hot water delivered to plumbing fixtures used by clients to attain a temperature of not less than 105 degrees F and not more than 120 degrees F. This posed a potential personal rights risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 10/30/2024
Plan of Correction
1
2
3
4
During today's visit, adjustments were made to the facility's water heater, such that hot water at all taps used by clients were brought back into the range required by regulation. This resolved the deficiency.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/30/2024 05:56 PM - It Cannot Be Edited


Created By: Dang Nguyen On 10/30/2024 at 05:01 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and LPM observation, Licensee did not ensure that all containers, including movable bins, used for storage of soild wastes had tight-fitting covers kept on the containers. This posed a potential health and personal rights risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 11/30/2024
Plan of Correction
1
2
3
4
Licensee agreed to purchase tight-fitting covers for the three (3) trash cans which were missing them, and to E-mail photos of the lids on these trash cans with covers, to LPA, by the POC due date.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, Licensee did not have proof that the facility administrator received training on HIV and TB within the last two years, as required. This posed a potential health risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 11/30/2024
Plan of Correction
1
2
3
4
Licensee agreed to arrange for the facility administrator to obtain three (3) hours of training on HIV, and one (1) hour of training on TB. Licensee agreed to E-mail proof of training completion to LPA, by the POC due date.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5