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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037003702
Report Date: 03/08/2022
Date Signed: 03/08/2022 10:26:54 AM

Document Has Been Signed on 03/08/2022 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:TLC ADULT HOMEFACILITY NUMBER:
037003702
ADMINISTRATOR:MEEKS, CAROLYNFACILITY TYPE:
735
ADDRESS:18301 TOYON RD.TELEPHONE:
(209) 296-4035
CITY:PINE GROVESTATE: CAZIP CODE:
95665
CAPACITY: 3CENSUS: 1DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Carolyn MeeksTIME COMPLETED:
10:45 AM
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) Christina Valerio arrived at the facility unannounced to conduct an annual visit. LPA Valerio confirmed with Administrator Carolyn that 0 residents and staff have displayed any signs or symptoms of COVID-19 in the last 10 days.

LPA Valerio and Administrator Carolyn toured the physical plant inside and outside to ensure compliance of Title 22 regulations. LPA observed resident room to be clean and free of debris. Resident bathroom had required hygiene items, such as soap, hand sanitizer, paper towels, and a trash can with a lid. The common areas of the facility had the required furniture and furnishings. Medication lock box, sharps, and cleaning supplies Emergency exits were not blocked. LPA observed an adequate supply of food and an emergency supply of food located in the pantry and the freezer outside. LPA Valerio went over the facilities emergency disaster plan with Administrator Carolyn. Emergency drills/Fire drill log completed and posted on the wall. Fire Extinguisher is charged with last inspection on 06/21/21. Hot water was measured at 108.1*F, which is within the required range of 105*F - 120*F.

LPA interacted with 1 resident during the visit. Resident was observed eating breakfast, engaging in activities in bedroom, and talking on the phone. LPA Valerio reviewed resident 1 file, 1 staff file during visit, and medication records. Required documents up to date and in file. Administrator Certificate set to expire June of 2022, which administrator stated she is in the process of renewing.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Administrator Carolyn Meeks. A copy of the report was given and left a copy for Administrator Carolyn Meeks.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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