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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005328
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:52:45 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230915163050

FACILITY NAME:TLC HOMEFACILITY NUMBER:
306005328
ADMINISTRATOR:EDNA DE JESUSFACILITY TYPE:
735
ADDRESS:1707 S DALLAS DRIVETELEPHONE:
(714) 234-3499
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 4DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Corazon Gonzalez and Susan GonzalezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the visit, LPA toured the facility and reviewed and obtained a receipt for purchase of mattress. Regarding the allegation that facility has bed bugs, the investigation revealed the following: On 08/12/2023, an area of possible bug bite with itching was noted on Client 1 (C1). Client was taken to Kaiser Permanente Garden Grove, same day, and was seen by a nurse practitioner. Client was diagnosed with "Non venomous insect bite of upper arm." C1 was prescribed Triamcinolone, Zyrtek, and Benadryl caplets. Facility observed resident's mattress and bed frame for evidence of bed bugs and did not see anything. Per facility request, Licensee replaced the mattress and bed frame. Facility indicates no prior exposure to bed bugs in the facility with the same clients residing since opening. C1 resided in the facility for 11 days only and returned home to be with family on 08/18/2023. LPA observed C1's prior room with new furnishings. The client rooms in the facility werre clean and sanitary. CONTINUED ON LIC 9099C DATED 09/19/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230915163050
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME
FACILITY NUMBER: 306005328
VISIT DATE: 09/19/2023
NARRATIVE
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Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and copy of the report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3