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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209235
Report Date: 09/13/2025
Date Signed: 09/15/2025 09:50:25 AM

Document Has Been Signed on 09/15/2025 09:50 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:TLC HOME CARE 2FACILITY NUMBER:
157209235
ADMINISTRATOR/
DIRECTOR:		ARRIETA JR, RODRIGO A.FACILITY TYPE:
740
ADDRESS:207 RIESLING VINES STTELEPHONE:
(661) 203-7565
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 3DATE:
09/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Administrator Rodrigo Arrieta Jr
Staff Antonia Duadico 		TIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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On 09/13/25, Licensing Program Analysts (LPAs), L. Salazar and M. Garza arrived at the facility unannounced to conduct the required annual visit. LPAs were greeted by staff, stated the purpose of the visit and were allowed entry into the facility. Staff called Administrator, who was available via telephone.

LPAs toured the facility inside and out including entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPAs observed 3 residents in care at the time of visit. Facility is a 4 bedroom 2 bathroom home. Bathrooms were observed to have grab bars by the toilets and a grab bar in the shower used by residents. Resident bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction. Facility temperature was 76 degrees F. Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 110.4 degrees F. Smoke detectors were tested and observed to be operational. Fire Extinguisher was observed with a service date of 09/17/24. First aid kit was observed and contained all required items. Required postings were observed for Non-discrimination LGBTQ-A+, Personal Rights of Residents in RCFE and theft policy. No residents are receiving Hospice services residents or receiving Home Health care service.
The following issues were observed during todays visit: LPAs did not observe posting of facility's visitation policy, LETUSNO Complaint Poster, (PUB475) and Ombudsman poster. A sample of 7-day food source was observe to be expired. Oxygen was observed in master bedroom closet, unsecured and not on a stand. R1's file showed R1 had a hospital visit on 08/20/25 that was not reported to CCL. There have been zero incident reports submitted by facility in 2025. Resident records were reviewed. 2 out of 2 files to have blank forms in the file. Blank forms were Identification & Emergency information (LIC601), Pre-admission appraisals (LIC603), Personal Rights of residents in care (LIC613C2), personal property and valuables (LIC621), Centrally stored medical and destruction record (LIC622), Appraisal/Needs service plan (LIC625), and Consent for medical treatment (LIC627C). Staff record were reviewed. 1 of 3 staff files was missing from facility. 2 of 2 staff files observed to be incomplete: Health screening report/TB testing (LIC 508), missing training hours (initial/ongoing). (Continued on LIC 809C)
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Lisa Salazar
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2025
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 09/15/2025 09:50 AM - It Cannot Be Edited


Created By: Lisa Salazar On 09/13/2025 at 05:29 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 2
FACILITY NUMBER: 157209235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(3)(E)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation of unsecure oxygen tank in the master bathroom, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2025
Plan of Correction
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Administrator has removed oxygen tank from facility. Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Lisa Salazar
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 09:50 AM - It Cannot Be Edited


Created By: Lisa Salazar On 09/13/2025 at 05:29 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 2
FACILITY NUMBER: 157209235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review of R1's file shows R1 went to the hospital on 08/20/25 and the licensee did not comply with the section cited above in 1 out of 1 persons in care which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator will submit proof of training/understanding of regulations by POC date.
Type B
Section Cited
CCR
87218(a)(1)
Theft and Loss
(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee and the resident or the resident's representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review, the licensee did not comply with the section cited above in 2 out of 3 resident files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator will provide proof of property inventory (LIC621)
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Lisa Salazar
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2025


LIC809 (FAS) - (06/04)
Page: 4 of 25
Document Has Been Signed on 09/15/2025 09:50 AM - It Cannot Be Edited


Created By: Lisa Salazar On 09/13/2025 at 05:29 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 2
FACILITY NUMBER: 157209235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator will obtain posters and send proof of posting by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Lisa Salazar
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 25
Document Has Been Signed on 09/15/2025 09:50 AM - It Cannot Be Edited


Created By: Lisa Salazar On 09/13/2025 at 05:29 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 2
FACILITY NUMBER: 157209235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that a sample of 7 day non perishable food source was pulled and reviewed. 3 of 5 cans were expired. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Staff stated they will audit the food source and dispose of all expired foods in the 7 day supply. Staff stated they will purchase additional food as needed and provide a receipt to CCL by POC date as proof of correction.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs records review), the licensee did not comply with the section cited above in 2 out of 3 records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator will complete the LIC 601, LIC 603/LIC 603A , LIC 613C2,and LIC 625, LIC627C for resident R1 and R2 by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Lisa Salazar
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2025


LIC809 (FAS) - (06/04)
Page: 6 of 25
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: TLC HOME CARE 2
FACILITY NUMBER: 157209235
VISIT DATE: 09/13/2025
NARRATIVE
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(continued from LIC 809)


Based on LPAs observations and records review and per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiencies are being cited on the attached 809-D's. If not corrected, this poses a potential/immediate health, safety or personal rights to persons in care.

LPA is requesting the following due by 09/26/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrative Organization (LIC 309), Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), and current liability insurance.

Exit interview was conducted with Antonia Duadico, A copy of this report and appeal rights were discussed and provided. A plan of correction was developed and reviewed with LPA.

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Lisa Salazar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2025
LIC809 (FAS) - (06/04)
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