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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 01/25/2024
Date Signed: 01/25/2024 07:15:53 PM


Document Has Been Signed on 01/25/2024 07:15 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: 7DATE:
01/25/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Jason PinedaTIME COMPLETED:
01:00 PM
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On 01/25/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Administrator, Jason Pineda, and explained the purpose of the visit.

A non-compliance conference was held on November 9, 2023. During non-compliance meeting, the following violations were discussed: General Food Service Requirements, Reappraisals, Storage Space, Incidental Medical and Dental Care, Alterations to Existing Building or New Facilities, Postural Supports, Care of Persons with Dementia, Exceptions for Health Conditions, Maintenance and Operations, Emergency Disaster Plan, Emergency Plans, Fire Clearance, Care of Bedridden Residents.

During the visit, LPA reviewed four resident records, all have updated and signed appraisals. Chemicals are all in a locked cabinet. Medications are updated and logged in centrally stored medication and are in a locked cabinet. Food supply in the facility is enough and there are no expired food found. Emergency drills are conducted quarterly, latest of which is done on October, 29, 2023. Kitchen sink has a permit issued on 9/26/200 hence it's been there before the facility was licensed in 2019. Room 3 wall has been patched and fixed. Fire clearance was not approved for bedridden residents, but as of now no residents in the facility are bedridden. Facility has an updated LIC610 Emergency Disaster Plan. Door alarms for rooms of dementia residents are in good working condition.

LPA observed two residents, R3 & R4, who were previously bedridden are capable of transferring with assistance and when in bed are able to turn and move on their own. LIC602 for both were also updated to be non-ambulatory.

No citations issued today. Report is reviewed with Administrator and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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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