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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037003702
Report Date: 02/23/2023
Date Signed: 02/23/2023 10:25:06 AM

Document Has Been Signed on 02/23/2023 10:25 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:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Carolyn MeeksTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual inspection. LPA met with Administrator Carolyn Meeks, and explained the purpose of the visit.

LPA completed the infection control tool. LPA and Administrator toured the facility to ensure compliance with Title 22 regulations. LPA observed the resident bedroom. The bedroom were observed to have necessary furniture and furnishings. The rooms were organized and free from debris. The bathrooms were observed to be clean and free from debris. The hot water measured at 106.2*F, which is within the regulatory range. The facility is equipped with an emergency supply of food and water, a supply of perishable foods for seven days, and a supply of non-perishable food for a minimum of two days. The facility is equipped with an all house generator should the power go out. Fire extinguishers were observed to be in working condition and up to date. Medications, sharps, and cleaning supplies were observed to be locked away and inaccessible to residents in care.

LPA requested the following documentation be sent to the Regional Office: LIC 500 Personnel Summary, LIC 308, LIC 610, Surety Bond

No deficiencies were observed during today's visit. An exit interview was held with Administrator Carolyn, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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