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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 06/21/2023
Date Signed: 06/21/2023 11:21:18 AM


Document Has Been Signed on 06/21/2023 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:TLC HOME CARE IIFACILITY NUMBER:
385600454
ADMINISTRATOR:MAURICIO, LILIAFACILITY TYPE:
740
ADDRESS:110 VALE AVENUETELEPHONE:
(415) 753-3216
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:9CENSUS: 8DATE:
06/21/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator/Caregiver, Jason PinedaTIME COMPLETED:
11:30 AM
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On June 21, 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced health and safety case management visit. LPA met with caregiver Jason Pineda who also stated to be the administrator of the facility. LPA explained the purpose of the visit.

LPA toured the facility and grounds based on the facility sketch . No accessible bodies of water or fire safety hazards observed. This is a two story facility. On the first floor, LPA observed one shared resident room, one private room, two staff rooms, laundry room and garage. Communal bathroom was observed to be clean. Shower was equipped with non-skid mats.

LPA toured the second floor and observed, kitchen, living room and dining room to be clean and odor-free. LPA observed six residents were watching television in the living room with one caregiver present. A comfortable temperature is maintained and lighting is sufficient for comfort. There are 4 residents room on the second floor.

LPA observed toxins, chemicals, and sharps to be locked and inaccessible to residents in care. Medication cabinet was observed to be locked and inaccessible. First aid kit was observed to be present and complete.

LPA observed washer and dryer in good repair and extra linen was observed to be present. Detergent and cleaning solution was observed to be locked.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TLC HOME CARE II
FACILITY NUMBER: 385600454
VISIT DATE: 06/21/2023
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During today's visit, LPA requested the following documents to update facility administrator: A written letter from the Licensee appointing the current administrator for the facility, revised LIC 500, LIC 501 and LIC 308, and a copy of control of property to be submitted to CCL by 6/22/2023.

No deficiency cited today.

Report is reviewed with administrator/caregiver; a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC809 (FAS) - (06/04)
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