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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880939
Report Date: 11/27/2023
Date Signed: 11/27/2023 01:45:14 PM


Document Has Been Signed on 11/27/2023 01:45 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: 6DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Adelaida Dy Support Staff TIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA's) 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.

LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

The Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient furniture and lighting and is maintained at a comfortable temperature.

There was enough nonperishable and perishable food for the number of residents in care. The facility has a variety of food available for residents, and a menu was available for review. The facility food is stored in a safe and healthful manner. Sharps are stored and locked cabinet inaccessible to clients in care. The resident’s bedrooms are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting.

All bathrooms were operating in a safe and sanitary conditions. The hot water temperature measured between 105- and 120-degrees F. LPA also observed the facility is equipped with operating carbon monoxide/smoke detectors and fully charged fire extinguishers.

Posters such as personal rights and the disaster plan were posted in a common area.

LPA did observe cleaning supplies, toxins items are kept in a locked cabinet on the porch back inaccessible to clients in care. The resident’s files were reviewed, and all files had the required documents at the time of the visit. The staff files were missing current and past training's a Technical Advisory (TA) has been cited for licensee to have training documents available for review by 12/11/2023.

An exit interview was conducted with Adelaida Dy where this report was discussed will be emailed to the licensee by the end of the day.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
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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