037003702-4-3-2026-27-AS-KVIA-DSSUPA-20260403154512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 037003702
Report Date: 04/03/2026
Date Signed: 04/03/2026 03:45:45 PM

Document Has Been Signed on 04/03/2026 03:45 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	TLC ADULT HOME		FACILITY NUMBER:	037003702
ADMINISTRATOR/ DIRECTOR:	MEEKS, CAROLYN		FACILITY TYPE:	735
ADDRESS:	18301 TOYON RD.		TELEPHONE:	(209) 296-4035
CITY:	PINE GROVE	STATE: CA	ZIP CODE:	95665
CAPACITY: 3		CENSUS: 1	DATE:	04/03/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Carolyn Meeks		TIME VISIT/ INSPECTION COMPLETED:	04:00 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	On 04/03/2026, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and met with the Licensee/Administrator, Carolyn Meeks. This LPA toured the kitchen and found a food supply of 2-day perishable and 7-days non-perishable. All resident medications were in a locked cabinet in the kitchen and inaccessible to the resident in care. The fire extinguisher was last inspected on 06/03/25 by Sierra Foothill Fire Extinguisher. It was not in compliance at the time of this inspection. Meeks stated that the representative from that company came on a yearly schedule and that Meeks had never had to call and arrange for the inspection previously. Meeks contacted the company during this visit and they explained that that representative was no longer with the company. Meeks contacted Cisco Fire Sprinklers and they will be out on 04/09/26 to inspect the fire extinguisher. Meeks will send a copy of the receipt for this service to CCLASCPSacramentoSouthRO@Dss.ca.gov as proof of compliance. LPA provided technical assistance regarding the need to schedule these inspections going forward. The bathroom had the required soap and paper towels and the first aid kit which was stored in the bathroom under the sink contained all of the required elements to be in compliance at the time of this inspection. LPA toured the home and found it to contain all of the required furniture and furnishings to be in compliance at the time of this inspection. The resident's (R1's) room also had the required lock for privacy if they decided to use it. LPA toured the exterior of the building and observed that all windows and screens were in good repair.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 04/03/2026 03:45 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 04/03/2026 at 02:30 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TLC ADULT HOME	FACILITY NUMBER: 037003702
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(k)(7)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above when they did not maintain a centrally stored medication log book in order to track when new medications were dispensed (or discontnued/ destroyed). This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2026
	Plan of Correction
1 2 3 4	Medications will all be checked to ensure they are current and the Licensee/Administrator has stated they will srta a new Centrally stored Medication Log. Pictures will be sent to Licensing to ensure compliance within 24 hours.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TLC ADULT HOME	FACILITY NUMBER: 037003702
	VISIT DATE: 04/03/2026

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Currently Meeks is the sole caregiver as her previous employee moved out of state. LPA explained for future reference, that anyone who comes into the home on a regular basis to assist with housekeeping or meal preparation needed to be background cleared. Even if this person was not to provide direct care, they would need to have the proper background clearance.

Meeks herself could not produce her Administrator's Certificate, but she did provide documentation showing she had taken the classes to renew her certificate along with a copy of the check used to pay her fees. This LPA confirmed that her certificate was active.

LPA reviewed R1's medications. LPA observed that Meeks had a Medication Administration Log which appeared to be up to date. Meeks did not have a current Centrally Stored Medication or Destruction Log so it was impossible for this LPA to determine when bottles were originally opened. Two of the prescriptions for two different medications were reduced. Meeks stated that she continued to use the bottles she had so she would not run out. Meeks showed this LPA 11 bags of medications that were delivered but not opened. Some were for medications taken on an "as needed basis" others were for the 2 medications that were reduced. This deficiency was cited on the LIC 9099D page. Meeks stated that she will look into getting the prescriptions in bubblepacks going forward.

According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Meeks.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026

LIC809 (FAS) - (06/04)

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