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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:23:25 PM


Document Has Been Signed on 10/20/2023 01:23 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:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nieves Sulayao, CaretakerTIME COMPLETED:
01:30 PM
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On October 20, 2023, Licensing Program Analysts, John Calandra and Audrey Jeung arrived at the licensed facility for an unannounced POC visit to follow up on deficiencies cited on 10/18/23 during a case management visit. The LPAs met with Nieves Sulayao and Alicia Lapuz and explained the purpose of their visit.

Acknowledgement of corrections is given to Caretaker, Nieves Sulayao- 2 pages.

The following deficiencies still exist, as plan/proof of corrections has not yet been received by due date of 10/19/23. Licensee is granted an extension, as requested, and must submit corrections by 10/24/23.

Section: 87204(a) LIMITATIONS--CAPACITY/AMBULATORY STATUS: Bedridden client resides in non-ambulatory room.

Section 87608(a)(5)(B): Postural Supports: Client in room 5 has full bed rail and is not on hospice.


Jason Pineda, the Administrator informed LPA, John Calandra via email that he had contacted family and they had reached out to the resident's family regarding the bed rails.



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)
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