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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880939
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:36:03 PM


Document Has Been Signed on 09/08/2022 03:36 PM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:TLC HOME CAREFACILITY NUMBER:
361880939
ADMINISTRATOR:MATE, KELVINFACILITY TYPE:
740
ADDRESS:30886 SUTHERLAND DRIVETELEPHONE:
(909) 351-6012
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:6CENSUS: 5DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Adelaida Dy- Caregiver TIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to initiate annual inspection, LPA met with Adelaida Dy- Caregiver

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients.

LPA toured the facility inside and out and there were no health and safety concerns. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The outdoor and indoor hallways were also free of obstruction.

Cleaning supplies are locked in the cabinets in the laundry area.

The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review.

The client rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature in the main bathroom. The hot water temperature measured at 105.6 degrees F.

LPA observed hand sanitizer throughout the facility and a 30- day supply of PPE. LPA Allen observed that all emergency contact information for the clients were up to date.

continued....

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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 3


Document Has Been Signed on 09/08/2022 03:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: TLC HOME CARE
FACILITY NUMBER: 361880939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87335(e)


This requirement is not met as evidenced by:
Deficient Practice Statement
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During the tour, LPA confirmed that Staff #2 had criminal record clearances but was not associated to the facility. This poses an immediate health & safety risk to the clients in care. LPA was informed that Staff #2 has worked at this facility since 7/1/2000. A civil penalty of $500 was assessed on 9/8/2022.
POC Due Date: 09/09/2022
Plan of Correction
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The lincessee will ensure that S#2 will be associated to the facility by the POC date 9/9/2022 through the Gardian System.
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.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: TLC HOME CARE
FACILITY NUMBER: 361880939
VISIT DATE: 09/08/2022
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During the tour, LPA confirmed that Staff #2 had criminal record clearances but was not associated to the facility. This poses an immediate health & safety risk to the clients in care. LPA was informed that Staff #2 has worked at this facility since 7/1/2000. A civil penalty of $500 was assessed on 9/8/2022.

LPA Allen conducted an exit interview where this report was discussed with the caregiver Adelaida Dy was given a copy of the LIC809, LIC809-C, LIC809-D and LIC421BG with appeal rights were provided at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3