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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604237
Report Date: 10/16/2023
Date Signed: 10/16/2023 12:58:24 PM


Document Has Been Signed on 10/16/2023 12:58 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: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:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Lauretta Bordon, Licensee/AdministratorTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Administrator Lauretta Bordon. LPA discussed the purpose of the visit with Administrator Bordon.

According to the facility’s license, there may be a maximum of four (4) non-ambulatory residents at any given time at the facility site. During today’s inspection, the facility’s current census is three (3) residents living at the facility; one (1) client was present at the facility site during the inspection. The facility is undergoing a change of facility status to change residents served to clients.

LPA, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Residents bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking, dining equipment and utensils were present and safely stored. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in a locked cabinet.

No pools or bodies of water on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

[CONTINUED ON LIC 809-C]
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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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: TENDER LOVING CARE HOME FOR ELDERLY
FACILITY NUMBER: 374604237
VISIT DATE: 10/16/2023
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[CONTINUED FROM LIC 809]

LPA reviewed staff and client records/files. During today’s visit, all clients were off-site at a day program but there was one resident who was interviewed. LPA observations of the facility and records did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Administrator Lauretta Bordon to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested 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: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
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