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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 10/18/2023
Date Signed: 10/18/2023 06:32:51 PM


Document Has Been Signed on 10/18/2023 06:32 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:
10/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Administrator, Jason PinedaTIME COMPLETED:
06:45 PM
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On October 18, 2023, Licensing Program Analysts (LPA) John Calandra and Audrey Jeung conducted an unannounced plan of correction (POC) visit to follow up on a Case Management visit made on October 4, 2023. LPAs Calandra and Jeung met with Administrator, Jason Pineda, Esther, and Nieves, caregivers, and explained the purpose of their visit.

On 10/4/2023, the facility was cited for California Code of Regulation (CCR), 87303(a): Maintenance and Operation, 87608(a)(3)(Postural Supports), 8755(b)(8)(general food service requirements), 87463(c)(appraisals), 87309(a)(1)(Storage Space, and 87465(h)(2)(internal medication and dental care). The plan of correction for these citations was submitted to CCLD on 10/8/2023.

Deficiency 87305(a) Alterations to Existing Buildings still exists, as plan/proof of correction has not been received. A copy of approved building permit and revised facility sketch showing the wet bar are requested to be submitted to CCLD by 10/25/2023.

On 10/18/2023, LPA Calandra and LPA Jeung observed proof of correction. Outstanding deficiencies are now verified as corrected and cleared. Acknowledgement of corrections is given to administrator--6 pages.

Report is reviewed with Administrator and copies are provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (510) -33-6009
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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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