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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005328
Report Date: 05/16/2024
Date Signed: 05/16/2024 10:36:43 AM

Document Has Been Signed on 05/16/2024 10:36 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/
DIRECTOR:		EDNA DE JESUSFACILITY TYPE:
735
ADDRESS:1707 S DALLAS DRIVETELEPHONE:
(714) 234-3499
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Susan Gonzales, House ManagerTIME VISIT/
INSPECTION COMPLETED:
10:37 AM
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 On today's date, Licensing Program Analysts (LPAs) Rosie Quiroz and Michael Tea conducted an unannounced Annual Required-1 year inspection visit. LPAs were granted entry by Live in House Manager (HM) Susan Gonzales. LPA Quiroz called Administrator (AD) Nadine Rojas to inform her about LPA's unannounced visit.
AD Nadine Rojas reported being on premises more than 20 hours per week. AD Certificate for Nadine Rojas expires on 2/22/2025.
This is a leveI 3 Facility licensed for a capacity of six clients, (6) Ambulatory clients providing services to Adult clients with Developmental Disabilities ages 18-59. At 9:09am, LPA Quiroz reviewed whether the following is in compliance: licensee is operating the facility within the conditions and limitations, which are specified on the license, including the capacity limitation.
The facility is a 1 story home. The home consists of: 3 client shared bedrooms, 3 restrooms for clients and staff , living room, kitchen with dining area, activity room, 1 staff office/lounge room, 2 car garage and back yard with gated and secured swimming pool. HM reported, "The clients don't really use the pool." Two secured/ locked sheds observed in back yard area.
Between 8:55am-9:40am, LPAs reviewed 4 of 4 staff records, 4 of 4 client records and 4 of 4 Personal & Incidental funds records (P&I). Staff records, clients records and P&I funds were found to be within Title 22 California Code of Regulations (CCR).
At 9:42am, LPAs reviewed 4 of 4 client centrally stored medication records. LPAs observed medications are secured in a secured cabinet in dining area, not accessible to clients in care. 4 of 4 Medication records were found to be within Title 22 CCR.
At 9:55am, LPAs along with HM Gonzales conducted the tour inspection. A tour of the interior and exterior of the facility and physical plant were inspected, including but not limited to testing hot water temperature in resident and common bathrooms. The resident bathroom water tested and measured between 104.9- 105.8 degrees Fahrenheit. All smoke detectors, carbon monoxide, were operational and functional.
CONTINUED ON LIC 809-C PAGE...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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 HOME
FACILITY NUMBER: 306005328
VISIT DATE: 05/16/2024
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CONTINUED... LPAs verified if facility is providing a comfortable temperature due to hot/cold weather condition. Facility has a working centralized heater and air conditioner to use for the cold or hot weather as needed. The temperature inside the facility was recorded to be 74 degrees Fahrenheit.
LPAs reviewed facility telephone; provision of sufficient lighting; exit obstructions, if any; and potential hazards. Poisons, toxic substances, and other dangerous objects were noted to be secured in kitchen cabinet area and inside garage not accessible to clients in care. Kitchen knives were stored and secured in kitchen cabinet, not accessible to clients in care.
The Outside grounds were inspected during facility tour. LPAs observed a swimming pool with secured and locked gate. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.
HM reported offering the following indoor and outdoor activities at the facility according to weather conditions: "Baking, watching movies, arts and crafts, neighborhood walks, shopping, dining out, Church on Sundays, Walks to Mojeska Park, Outings to Cerritos Mall and Park picnics."
Two fire extinguishers observed and fully charged, and last tested on October 16, 2023. HM reports fire drills are conducted with staff and clients. Last facility fire drill was conducted on January 12, 2024.
Plentiful basic hygiene items and linen supply were available. First Aid KIT and other aide supplies were observed to be stored in secured cabinet in kitchen area. Furnishing cleanliness and state of repair, and fixtures were examined. Nonskid mats were observed in client restrooms. Operational and functional Washer and Dryer were observed in garage area.

Based on the observations made during today’s visit, there are NO deficiencies being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with HM Susan Gonzales, and a copy of this report along with the LIC 858, LIC 859 were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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