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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604237
Report Date: 10/12/2022
Date Signed: 10/12/2022 01:34:59 PM


Document Has Been Signed on 10/12/2022 01:34 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: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: 4DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lauretta Bordon, Licensee, and Coleen Bordon, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Lauretta Bordon, Licensee, and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA accompanied by Licensee Bordon conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing/hand hygiene practices, cough and sneeze etiquette and other infection control procedures; testing plan and procedures for staff and clients; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

LPA provided updated guidance with current PINs for Resident Cohorting, Isolation and Quarantine, Staffing and Use of Personal Protective Equipment Based on Resident Coronavirus Disease 2019 (COVID-19) Status; Best Practices for Visitation Related to Coronavirus Disease 2019 (COVID-19) and the Recession of the Statewide Visitation Waiver; Updated Adult and Senior Care Facility Worker Coronavirus Disease 2019 (COVID-19) Vaccination, Booster, and Testing Information; and California Department of Public Health (CDPH) Recommendations for Coronavirus 2019 (COVID-19) Vaccines and Updated Booster Doses.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Licensee Bordon, and Administrator Collen Bordon. A copy of this report, along with the Licensee Rights (3/22) was provided to Licensee Bordon at the conclusion of the visit. The signature below serves as confirmation of receipt of these documents.

LPA requested for Licensee and Administrator Bordon to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms available at www.ccld.ca.gov.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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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