361880939-11-19-2024-56-AS-BALN-DB72DC-20241119161808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880939
Report Date: 11/19/2024
Date Signed: 11/19/2024 04:18:17 PM

Document Has Been Signed on 11/19/2024 04:18 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 CARE		FACILITY NUMBER:	361880939
ADMINISTRATOR/ DIRECTOR:	MATE, KELVIN		FACILITY TYPE:	740
ADDRESS:	30886 SUTHERLAND DRIVE		TELEPHONE:	(909) 351-6012
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY: 6		CENSUS: 6	DATE:	11/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Adelaida Dy -Support Staff		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility to conduct an annual inspection. At the time of the visit there were two (2) staff members and six (6) residents. LPA met with Adelaida Dy who was informed of the purpose of the visit and she assisted with the tour of the facility.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 73 degrees. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The water was measured at 105-120 degrees.

LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, fully charged fire extinguisher, and carbon monoxide alarms.

Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care.

LPA observed there was a designated storage space for resident/staff files.

Medications are kept locked inaccessible to residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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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Document Has Been Signed on 11/19/2024 04:18 PM - It Cannot Be Edited

Created By: Bernadette Allen On 11/19/2024 at 03:35 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TLC HOME CARE	FACILITY NUMBER: 361880939
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)-(h)

(c)-(h)Licensees shall maintain in the personnel records verification of required staff training and orientation.... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, and record review the licensee did not comply with the section cited above. LPA reviewed Staff 1 and Staff 2 files that did not have the required annual training. The licensee did not ensure staff members had the required annual trainings up to date which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to provide the required annual training to all staff members by the POC date of 11/26/2024 and provide signed proof of training to LPA by the poc date of 11/26/2024.

Type B

Section Cited

CCR

87611(b)(1)(f)

(b) (1)(f)The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following:..... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above Resident 1 didn't have a needs/service plan or physicians report, Resident 2 didn't have needs & service plan,Appraisal not signed/dated, and Resident 3 didn't have needs & and service plan/ emergency information not signed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to provide proof of completed files for Resident 1, Resident 2 and Resident 3 with all required documents by the POC date of 11/26/2024.

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 Clemons

LICENSING EVALUATOR NAME:

Bernadette Allen

LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TLC HOME CARE	FACILITY NUMBER: 361880939
	VISIT DATE: 11/19/2024

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Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans which were not up to date. The licensee has agreed to update Resident 1, Resident 2 and Resident 3 files with current needs and service plans, physicians reports and updated emergency information sheet.

LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, there was no current training's on file for staff members Staff 1 and Staff 2. The licensee has agreed to provide training to staff members and provide proof of training once completed.

Based on the observations made during today’s visit, deficiencies were cited. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

An exit interview was conducted, and this report was discussed and provided to Adelaida Dy- Support staff at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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