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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 01/15/2025
Date Signed: 01/15/2025 03:36:33 PM

Document Has Been Signed on 01/15/2025 03:36 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/
DIRECTOR:
CIRILA G. MAURICIOFACILITY TYPE:
740
ADDRESS:110 VALE AVENUETELEPHONE:
(415) 753-3216
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY: 9TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:56 AM
MET WITH:Cirila MauricioTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 1/15/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Cirila Mauricio and explained the purpose of the visit.

LPA toured the facility inside and outside including resident rooms, common areas, and kitchen area. Facility has 2 floors. Downstairs rooms has 2 resident rooms, one of which is a shared room. Upstairs rooms have 4 bedrooms, one of which is also shared. While touring the facility it was observed that the temperature was at 69 deg F. Hot water was also tested in the resident rooms and the temperature was 108 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms were observed to be in good repair and adequate lighting. Bathrooms are equipped with grab bars and non-skid floors. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency food supply is updated and stored. Emergency drills are logged and done every quarter.

Six resident records and six staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested the following documents: Liability Insurance. LPA received a copy of the LIC500, Control of Property and LIC308.

No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided.
Andrea MedlinTELEPHONE: (650) 266-8811
Grace DonatoTELEPHONE: (714) 293-8294
DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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