<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:45:10 PM


Document Has Been Signed on 10/20/2023 01:45 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: 7DATE:
10/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Nieves Sulayao, CaretakerTIME COMPLETED:
02:00 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 October 20, 2023, Licensing Program Analysts, John Calandra and Audrey Jeung arrived at the facility to cite for a deficiency observed on 10/18/2023. The LPAs were greeted by Angie Lapuz and Nieves Sulayao, both Caretakers.

The LPAs toured all rooms including but not limited to bedrooms, bathrooms, a kitchen, living room, etc. LPAs Calandra and Jeung observed half bed rails in all resident bedrooms and a full bed rail in bedroom 5.
Review of all client files is done. There is another resident who is bedridden in room 2 on 2nd floor.
See separate Facility Evaluation Report dated 10/20/23 for additional deficiencies observed.

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 Nieves Sulayao, Caretaker. 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: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/20/2023 01:45 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: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2023
Section Cited
CCR
87202(a)(2)

1
2
3
4
5
6
7
 Fire Safety: All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met, as there is a bedridden client in room 2 upstairs and 5 downstairs.
1
2
3
4
5
6
7
Licensee shall submit plan/proof of correction to CCLD by due date.
8
9
10
11
12
13
14
Licensee failed to comply with conditions and limitations of fire clearance approved for 9 non-ambulatory clients, and no bedridden, which poses an immediate health, safety, and personal rights risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2