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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604237
Report Date: 10/12/2022
Date Signed: 10/12/2022 01:36:40 PM


Document Has Been Signed on 10/12/2022 01:36 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lauretta Bordon, Licensee, and Colleen Bordon, AdministratorTIME COMPLETED:
01:45 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) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection and in conjunction conducted a case management visit to and gave the facility additional guidance. LPA identified herself and was granted entry by Licensee Lauretta Bordon. LPA met Lauretta Bordon, and discussed the purpose of today’s visit.

During today’s visit LPA went over Title 22, Division 6, Chapter 8, Section 87211 Reporting Requirements; and Chapter 3.2 Health and Safety (H&S) Code Regulations Section 1507.15 Absentee notification plan for missing residents or participants; and H&S code Section 1569.317 Absentee notification plan for missing residents with Licensee Bordon and Administrator Colleen Bordon. LPA additionally provided Licensee Bordon guidance on Records to be Maintained at the Facility – Residential Care Facility for the Elderly (LIC311F) and provided a copy of the LIC311F. Based on today’s inspection no deficiencies were cited.

An exit interview was conducted with Licensee Bordon and Administrator Colleen Bordon. A copy of this report, along with the Licensee Rights (03/22) was provided to Licensee Bordon at the conclusion of the visit. The signature below serves as confirmation of receipt of these documents.
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)
Page: 1 of 1