385600454-2-13-2024-14-AS-JCAA-D2EVX4-20240213154854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 02/13/2024
Date Signed: 02/13/2024 03:48:59 PM

Document Has Been Signed on 02/13/2024 03:48 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 II		FACILITY NUMBER:	385600454
ADMINISTRATOR:	JASON PINEDA		FACILITY TYPE:	740
ADDRESS:	110 VALE AVENUE		TELEPHONE:	(415) 753-3216
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94132
CAPACITY:	9	CENSUS: 7	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:54 AM
MET WITH:	Jason Pineda, Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On February 13, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 11:54 AM to conduct an unannounced Annual 1-year required inspection. LPA Calandra met with Jason Pineda, Administrator and explained the purpose of his visit. LPA Calandra toured the physical plant. This is a two story building that consists of 6 bedrooms and 3 bathrooms. Water in all bathrooms was measured within the required range of 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last checked on October 30, 2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature was within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility's first aid was observed to be complete. The facility does not handle any cash resources. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. All knives and sharp objects were observed to be locked and in-accessible to persons in care. All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility. LPA Calandra also reviewed 5 resident and 5 staff files. All were observed to be complete.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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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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: 02/13/2024

NARRATIVE

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During today's visit, Type B violations were issued for the facility administrator failing to provide both a Fire Safety Plan (HSC 87212(b)(2)(a)-Emergency Disaster Plan) and Evacuation Procedures, including identification of an assembly point or points that shall be included in the facility sketch.(HSC 1569.695)

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.

This report was reviewed with Administrator, Jason Pineda and a copy along with appeal rights left at the facility.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2024 03:48 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: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)(1)

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview of Administrator, the licensee did not comply with the section cited above in 1 out of 1 facility sketches which did not show evacuation procedures, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Type B

Section Cited

CCR

87212(b)(2)(A)

Emergency Disaster Plan

(b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including: (A) Fire safety plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview of Administrator, the licensee did not comply with the section cited above in 1 out of 1 Fire Safety Plans which the Administrator could not produce, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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