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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604237
Report Date: 07/01/2022
Date Signed: 07/01/2022 10:26:29 AM


Document Has Been Signed on 07/01/2022 10:26 AM - 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:TENDER LOVING CARE HOME FOR ELDERLYFACILITY NUMBER:
374604237
ADMINISTRATOR:BORDON, LAURETTA MFACILITY TYPE:
740
ADDRESS:165 PALAWAN WAYTELEPHONE:
(619) 370-8008
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:4CENSUS: 3DATE:
07/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lauretta Bordon, LicenseeTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Carmen Lopez and County of San Diego Nurse Contractor, Robert Montillano with the HAI Program, conducted an on-site HAI assessment visit. LPA and team identified themselves and discussed the purpose of the visit with Licensee Lauretta Bordon, and Melanie Miranda, volunteer care staff.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan on the COVID-19 protocols and procedures to include cleaning and disinfection, testing, isolation and quarantine, hand hygiene and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, the team interviewed the Licensee and conducted a walk-though of the facility. A debriefing was conducted with the Licensee at the conclusion of the visit. During today's visit, no deficiencies were cited.

An exit interview was conducted with Melanie Miranda, volunteer care staff and Licensee Lauretta Bordon to whom a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided at the conclusion of the visit. The signature below serves as confirmation of receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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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