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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601423
Report Date: 02/04/2022
Date Signed: 02/07/2022 08:32:01 AM

Document Has Been Signed on 02/07/2022 08:32 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:TANGEM GUEST HOMEFACILITY NUMBER:
374601423
ADMINISTRATOR:ALEGRE, GEMMA T.FACILITY TYPE:
740
ADDRESS:6640 PARADISE CRESTVIEW WAYTELEPHONE:
(619) 434-9073
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 6CENSUS: 6DATE:
02/04/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Caregivers Evelia Guerta, Warlita Jimenez, and Staff Stanley AlegreTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an announced Case Management visit, accompanied by Nurse, Sandra Brackman, from the Healthcare Acquired Infection (HAI) team of San Diego County Health and Human Services Agency. LPA and HAI nurse were allowed entry into the facility, by Caregivers, Evelia Guerta and Warlita Jimienez, after identifying themselves and stating the purpose of the visit. Staff Stanley Alegre and Administrator Gemma Alegre arrived during the visit.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols, as well as the use of personal protective equipment (PPE). During today's visit, the caregivers, and staff were interviewed, and the team conducted a walk-though of the facility. A debriefing was conducted with the Caregivers and Staff at the conclusion of the visit.

During today's visit, no deficiencies were cited. An exit interview was conducted with Staff Stanley Alegre. A copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to Administrator Gemma Alegre via electronic mail. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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