374603627-10-8-2025-08-AS-DNGN-DM9VJ7-20251008162815

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603627
Report Date: 10/08/2025
Date Signed: 10/08/2025 04:28:58 PM

Document Has Been Signed on 10/08/2025 04:28 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/ DIRECTOR:	HENRIETTA CHONG		FACILITY TYPE:	735
ADDRESS:	1639 MARL AVE		TELEPHONE:	(619) 216-7836
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY: 6		CENSUS: 5	DATE:	10/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:14 PM
MET WITH:	Caregiver Alita Reyes and Licensee/Administrator Henrietta "Candy" Chong		TIME VISIT/ INSPECTION COMPLETED:	04:45 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 made an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alita Reyes. LPA then met with Licensee/Administrator Henrietta “Candy” Chong, who arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six (6) clients, of whom all may be ambulatory, three (3) may be non-ambulatory, and one (1) may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and interviews: During today’s inspection, there were a total of five (5) clients in care, and all were ambulatory. LPA interviewed all staff present and spoke with all clients in care. LPA reviewed all client files and the personnel records for all active staff. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility, and inspected all common areas and client bedrooms. 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 and screens, toilets, and showers were working. Extra linens, hygiene, and Personal Protective Equipment (PPE) 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. Hot water temperature at taps used for client grooming were all compliant in temperature: Bathroom #1 Sink was 118 F and Bathroom #2 Sink was 111 F. Refrigerators and freezers used to preserve perishable food were complaint in temperature. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present and in good condition. [CONTINUED ON LIC 809-C, 1 of 2]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 10/08/2025

NARRATIVE

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[CONTINUED FROM LIC 809] The facility did not have a fireplace or swimming pool (or similar body of water). There were no open-faced heaters, toxic chemicals/poisons, or other hazardous objects accessible to clients. Smoke detectors, 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. The facility’s license did not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present.

There was a locked area for storage of medication. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance and surety bond.

LPA observation, corroborated by staff interviews, showed: The facility is a two-story structure, meaning there are two (2) floors. All client bedrooms are on the first floor, while the live-in staff present during the overnight shift sleeps in the upstairs bedroom (rather than being continuously awake during the night). The facility is therefore required to have a working signal system operable from each client bedroom, which will transmit a signal to a central location or be loud enough to summon staff, and which will identify the specific bedroom from where the signal originates. During today’s inspection, 3 of 3 signal system devices (which were present in client bedrooms during the pre-licensing inspection) were either missing or non-working.

Review of staff training records, corroborated by manager interview, showed: Licensee did not ensure that 6 of 6 staff [Staff #1 (S1) through Staff #6 (S6)] had received training on the facility’s written Emergency Disaster Plan within the last year, as required.

One (1) deficiency was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC809-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Licensee/Administrator Henrietta “Candy” Chong, to whom a copy of this report, the LIC 809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/08/2025 04:28 PM - It Cannot Be Edited

Created By: Dang Nguyen On 10/08/2025 at 03:57 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: 10/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(b)

(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. 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 of training being provided to 6 of 6 staff (S1 through S6) on the facility's written emergency and disaster plan, within the last year. This posed a potential health and safety risk to 5 of 5 clients [Client #1 (C1) through Client #5 (C5)] in care.
	POC Due Date: 11/08/2025
	Plan of Correction
1 2 3 4	Licensee agreed to train S1 through S6 on the facility's LIC610D Emergency Disaster Plan, and to E-mail proof of training completion to LPA, by the POC due date. Going forward, Licensee agreed to repeat this training at least annually.

Type B

Section Cited

CCR

85088(f)(1)(C)

(1) In all facilities with a licensed capacity of 16 or more clients, and all facilities having separate floors or separate buildings without full-time staff there shall be a signal system which has the ability to meet the following requirements: (C) Identification of the specific client's living unit from which the signal originates. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and staff interview, the facility has seperate floors without full-time awake staff, but Licensee did not ensure the facility's signal system was working and capable of identifying the specific client's living unit from which the signal originates.
	POC Due Date: 11/08/2025
	Plan of Correction
1 2 3 4	Licensee agreed to purchase and install three (3) signal system devices (one for each client bedroom) capable of transmiting a signal to a central location or of being loud enough to summon staff, and which will identify the specific bedroom from where the signal originates. Upon completion, Licensee agreed to film short videos of the three devices in operation, and to send the footage 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.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

LIC809 (FAS) - (06/04)

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