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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 12/14/2023
Date Signed: 12/14/2023 01:13:15 PM

Document Has Been Signed on 12/14/2023 01:13 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:
12/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Nieves Sulayao, Caretaker TIME COMPLETED:
01:15 PM
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On December 14, 2023, Licensing Program Analyst(LPA) John Calandra and Licensing Program Manager(LPM) Jackie Jin, conducted an unannounced continuation of the Annual 1-year required inspection that was started on October 27, 2023. David and Bernice Orme, Administrators in charge while the Administrator, Jason Pineda is on vacation arrived and met with LPA Calandra and LPM Jin briefly during the visit but did not stay.

LPA Calandra and LPM Jin interviewed 3 residents and 3 staff.

No deficiencies were cited. A copy of this report was left at the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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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