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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209235
Report Date: 08/26/2024
Date Signed: 08/26/2024 01:39:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2024 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240816164101
FACILITY NAME:TLC HOME CARE 2FACILITY NUMBER:
157209235
ADMINISTRATOR:ARRIETA JR, RODRIGO A.FACILITY TYPE:
740
ADDRESS:207 RIESLING VINES STTELEPHONE:
(661) 203-7565
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 3DATE:
08/26/2024
UNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Facility Staff, Judy CabertoTIME COMPLETED:
01:47 PM
ALLEGATION(S):
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Facility staff did not respond to resident's ring bell
INVESTIGATION FINDINGS:
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On 08/26/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to commence a complaint investigation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA spoke with Administrator via telephone and received verbal permission to meet with

During the course of the investigation, LPA conducted a facility tour and interviewed staff. LPA confirmed did not hear the resident call button resulting in staff not responding timely to a residents call for assitance. Based on interviews the perponderance of evidence standard has been met therefore the allegation: Facility staff did not respond to resident's ring bell is SUBSTANTIATED.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 9099D. Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to ************************, whose signature on this form confirms receipt of this document.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20240816164101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 2
FACILITY NUMBER: 157209235
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2024
Section Cited
CCR
87411(d)(3)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... this requirement was not met as evidenced by:
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Licensee repaired the assigned bell. POC cleared.
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Based on interviews, the licensee did not comply with the section cited above when staff did not respond timely to a resident call for assistance, which posses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2