<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005328
Report Date: 05/10/2022
Date Signed: 05/10/2022 11:21:48 AM

Document Has Been Signed on 05/10/2022 11:21 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 HOMEFACILITY NUMBER:
306005328
ADMINISTRATOR:EDNA DE JESUSFACILITY TYPE:
735
ADDRESS:1707 S DALLAS DRIVETELEPHONE:
(714) 234-3499
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Susan Gonzales, House ManagerTIME COMPLETED:
11:21 AM
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 today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual Inspection. LPA Quiroz was greeted and granted entry into the facility by House Manager (HM) Susan Gonzales. LPA Rosie Quiroz explained the nature of the visit.(HM) Gonzales indicated COVID-19 screening all incoming visitors prior to entering the facility.
On or about 9:19am, LPA Rosie Quiroz reviewed 5 of 5 clients records. On or about 10:02am, LPA Quiroz along with (HM) Gonzales began the tour of the inside and outside of the facility. There are five clients in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed one of five residents in living room area interacting with (HM) Gonzales and LPA Quiroz and 3 of five residents in their bedrooms resting. (HM) Gonzales indicated Client 3 is currently at day program. Four of five clients present at the facility during today's visit appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility.
All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within normal ranges. LPA Quiroz inspected client’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in living room area readily available for staff and clients. LPA Quiroz toured the outside of the facility and observed seating and shaded area for clients and visitor's enjoyment. LPA Quiroz observed locked and secured swimming pool.
The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on June 16, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated June 14,2021. LPA Quiroz was informed that all clients have had their COVID-19 vaccinations and Boosters and will be speaking to Families to consent and schedule second booster. Facility is recording client's temperatures daily.
Continued on next page...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 HOME
FACILITY NUMBER: 306005328
VISIT DATE: 05/10/2022
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
26
27
28
29
30
31
32
Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

During today's visit, LPA Quiroz provided Consultation on Title 22 throughout today's visit.

This report was reviewed with (HM) Susan Gonzales and a copy of this report and LIC 811 Confidential Names were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2