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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:45:36 PM


Document Has Been Signed on 10/04/2023 04:45 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
SAN BRUNO RO, 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: DATE:
10/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jason Pineda, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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On October 4, 2023, Licensing Program Analyst John Calandra and Licensing Program Manager Cara Smith conducted an unannounced case management visit to the facility in regards to an incident report submitted. LPA Calandra and LPM Smith were greeted at the door by the Administrator, Jason Pineda and explained the purpose of today's visit.

LPA Calandra and LPM Smith toured the facility with Administrator, Jason Pineda and observed expired food, unsecured sharp objects, accessible medications, unsupervised residents, no call buttons in downstairs bedroom, unsecured medication, and lid free trash cans. The tour consisted of 3 bedrooms, the kitchen, dining room, living room, staff bedrooms, bathrooms, etc.

In Bedroom 3, the LPA and LPM observed a wall where the bed used to be, in disrepair. In the Kitchen, eggs were observed to be sitting on a counter, a slice of Carrot cake on a table, and perishable food items that needed to be refrigerated upon opening. Medications for both staff and residents were observed to be accessible to persons in care and expired food inside of the refrigerator. The LPA observed the administrator remove the items from the fridge and dispose of.

The tour continued downstairs where laundry detergent was observed on the floor of the staff room that was unsecured. Administrator, Jason removed the detergent. In R4's bedroom, a kitchenette was observed that is not displayed on the facility map. In the fridge, LPA Calandra and LPM Smith found expired foods. Next to the refrigerator, in an unsecured drawer were sharp knives. In the bathroom, a trash can with no lid and a air vent was covered with duct tape. In bedroom 2 downstairs, it was observed that bedrails on both beds were out of compliance.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (510) -33-6009
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TLC HOME CARE II
FACILITY NUMBER: 385600454
VISIT DATE: 10/04/2023
NARRATIVE
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The tour concluded in the staff bathroom on the first floor where medication was observed in a cabinet on the wall accessible to persons in care.

Records were reviewed for residents: R1, R2, and R3.

Documents were requested during the visit from the administrator including the LIC500, LIC 308, LIC 501, Administrator Certificate and LIC 508: Criminal Record Statement.

Deficiencies are cited under California Code of Regulations, Title 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator. A copy of this report and the Appeal Rights were provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (510) -33-6009
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 10/04/2023 04:45 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: TLC HOME CARE II
FACILITY NUMBER: 385600454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
87303(a)

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(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times.
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Administrator to have bedroom 3's wall to be patched and trash cans with no lids. Administrator to provide proof of correction to LPA after the work is completed and trash cans replaced.
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Based on observation, this requirement is not met by a wall in bedroom 3 where the bed used to be, in disrepair and trash cans in all rooms have no lids.
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Type B
11/01/2023
Section Cited
CCR87608(a)(3)

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Postural Supports (a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support.
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The administrator will review the regulation pertaining to Postural Supports and provide in-services to facility staff.
The administrator and/or designee will obtain a written physician's order for R2's half bed rails.
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This requirement is not met as evidence by: R2 has half bed rails up by the head of the bed and there was no written order from their physician which poses a potential health risks to residents in care.
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The administrator and/or designee will conduct an evaluation of all the resident's beds for postural supports and if one is being used, the facility will obtain a physician's order indicating the need for the device that is being used.
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: Cara SmithTELEPHONE: (510) -33-6009
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2023 04:45 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: TLC HOME CARE II
FACILITY NUMBER: 385600454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2023
Section Cited
CCR
87555(b)(8)

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General Food Service Requirements: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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Administrator removed all expired food and dispose of it in addition to placing all food that needs to be refrigerated in refrigerator. Administrator and/or designee shall review the regulation and provide-in services to facility staff.
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This requirement is not met as evidenced by interview of administrator and observation of a slice of Carrot cake on a table and multiple expired food/food products inside of refrigerators upstairs and downstairs.
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The administrator and/or designee shall obtain put in place a procedure to ensure food will be of good quality. .
Type A
10/05/2023
Section Cited
CCR87555(b)(23)

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General Food Service Requirements:All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections
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Administrator disposed of all perishable food that has not been refrigerated. Administrator to schedule regular checks of refrigerators in facility to ensure all readily persihable foods or beverages be stored in covered containers at appropriate temperatures.
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or food intoxications shall be stored in covered containers at appropriate temperatures.
This requirement is not met as evidenced by observation of food that needs to be refrigerated after opening not refrigerated.
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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: Cara SmithTELEPHONE: (510) -33-6009
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 10/04/2023 04:45 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: TLC HOME CARE II
FACILITY NUMBER: 385600454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2023
Section Cited
CCR
87303(a)

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Maintenance and Operation: (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator to have wall painted and/or patched and submit photo to LPA.
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This requirement is not met as evidenced by an interview with the administrator and observation of bedroom 3 which has a wall that needs to be patched and/or painted.
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Type A
10/05/2023
Section Cited
CCR87463(c)

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 Appraisals (c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months.
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The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months.
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This requirement is not met as evidence by record reviews of R1, R2, and R3. R1’s needs and services plan (LIC625) was dated 01/05/2022 and unsigned. R2 and R3 does not have a copy of the needs and services plan.
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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: Cara SmithTELEPHONE: (510) -33-6009
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 10/04/2023 04:45 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: TLC HOME CARE II
FACILITY NUMBER: 385600454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2023
Section Cited
CCR
87309(a)(1)

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Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Administrator removed liquid detergent from staff room. Administrator to schedule in-service with all staff to ensure that all liquid detergent is kept locked up and inaccessible to persons in care.
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(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not evidenced by interview with administrator and observation of chemicals on the floor and accessible to persons in care. This poses an immediate health and safety risk to persons in care.
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Type A
10/05/2023
Section Cited
CCR87465(h)(2)

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Incident Medication and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement is not met as evidenced by observation of staff and resident medication in areas throughout facility that are accessible to persons in care which poses an immediate health and safety risk to residents.
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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: Cara SmithTELEPHONE: (510) -33-6009
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 10/04/2023 04:45 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: TLC HOME CARE II
FACILITY NUMBER: 385600454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2023
Section Cited
CCR
87305(a)

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87305 Alterations to Existing Building or New Facilities:(a) Prior to construction or alterations, all facilities shall obtain a building permit.

Violation of this regulation is not met as evidenced by:
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Licensee shall submit a plan in writing to obtain a proper building permit prior to construction and alterations. Admininistrator will notify licensee to seek appropriate building regulators prior to construction.
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Based on observations conducted and interviews of staff and administrator, facility has installed a sink in R4's bedroom along with a toaster oven, mini fridge, and counter space for food preparation. This was not observed on the facility sketch and administrator was unaware of building permit.
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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: Cara SmithTELEPHONE: (510) -33-6009
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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