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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004759
Report Date: 11/23/2022
Date Signed: 11/23/2022 10:26:41 AM


Document Has Been Signed on 11/23/2022 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:TLC ELDERLY RESIDENCE 1FACILITY NUMBER:
306004759
ADMINISTRATOR:TALLAT BATLAFACILITY TYPE:
740
ADDRESS:25751 GOLDEN ROD CIRCLETELEPHONE:
(949) 367-9248
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:5CENSUS: 4DATE:
11/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Masroor BatlaTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Jessica Cho arrived at TLC Elderly Residence 1 to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 9:38am, LPA Cho was greeted and granted entry by Caregiver Jose Gomez. Also present was Maria Delaluz Castillo Garcia followed by Administrator (Admin) Masroor Batla and Licensee Tallat Batla. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a check-in station with a thermometer. LPA observed the required COVID-19 precautionary signs posted throughout the facility. The Complaint Poster (PUB475) was observed in the size of 7"x11" which did not meet the size requirement. The facility is licensed for five non-ambulatory residents and has a hospice waiver for four. There are currently four residents living in the facility of which two are receiving hospice care.

Approximately 9:50am, LPA Cho conducted a tour of the physical plant with Admin Masroor Batla. The facility is a two story home. There are a total of four resident bedrooms and two resident bathrooms on the first floor. The Licensee and the Administrator occupies on the second floor. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and slip mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including hand soaps and paper towels. LPA observed hand washing signs in the bathrooms. The hot water temperature in the resident bathrooms measured at 116.6 degrees Fahrenheit in Bathroom #1, 117.1 degrees Fahrenheit in Bathroom #2, and 117.8 degrees Fahrenheit in Bathroom #3. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged and purchased on 10/19/2022. Smoke/carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. The swimming pool gate was secured. There was shading and sufficient seating for residents. The exit gate was self-closing and self-latching. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TLC ELDERLY RESIDENCE 1
FACILITY NUMBER: 306004759
VISIT DATE: 11/23/2022
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Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit.

An exit interview was conducted with Administrator Masroor Batla, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC809 (FAS) - (06/04)
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