<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
385600454
Report Date:
10/27/2023
Date Signed:
10/27/2023 02:45:19 PM
Document Has Been Signed on
10/27/2023 02:45 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 II
FACILITY NUMBER:
385600454
ADMINISTRATOR:
MAURICIO, LILIA
FACILITY TYPE:
740
ADDRESS:
110 VALE AVENUE
TELEPHONE:
(415) 753-3216
CITY:
SAN FRANCISCO
STATE:
CA
ZIP CODE:
94132
CAPACITY:
9
CENSUS:
7
DATE:
10/27/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Alicia Lapuz, Caretaker
TIME COMPLETED:
03:15 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 27, 2023 Licensing Program Analyst(LPA) John Calandra, Grace Donato, and Licensing Program Manager(LPM) Cara Smith conducted an unannounced required 1 year annual inspection. LPA Calandra, LPA Donato, and LPM Smith were greeted by Caretaker, Alicia (Angie) Lapuz and explained the purpose of their visit.
The LPAs and LPM toured the facility inside and outside including the bedrooms (2 private rooms and 1 shared room), 2 full- bathrooms, kitchen, and common areas. The facility was observed to be clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 119 degrees Fahrenheit.
Toxins and sharps objects were locked and inaccessible to residents.
Medication review was completed, and all medications are accounted for, and centrally stored medication records are updated. Medication for one resident(ClearLax) was observed in the pantry in the kitchen unlocked and accessible to persons in care.
Resident and Staff records were reviewed; 2 days worth of perishables and 7 days of non-perishables were observed.
Facility is equipped with smoke detectors and carbon monoxide detectors.
LPAs and LPM reviewed 7 residents files and all of them contained admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, and etc.
Interview of staff and residents were not conducted at this time.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
John Calandra
TELEPHONE:
650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
10/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
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
7
Document Has Been Signed on
10/27/2023 02:45 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) 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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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 evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 6 bedrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/28/2023
Plan of Correction
1
2
3
4
Licensee and/or Administrator to deliver plan of correction to CCLD by 10/28/2023.
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) 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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 6 bedrooms which poses an immediate health, safety or personal rights risk to persons in care. Two residents are considered bedridden which the facility is not currently licensed for.
POC Due Date:
10/28/2023
Plan of Correction
1
2
3
4
Licensee and/or Administrator to deliver plan of correction to CCLD by 10/28/2023.
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
10/27/2023 02:45 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview of staff and record review, the licensee did not comply with the section cited above in 2 out of 7 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/28/2023
Plan of Correction
1
2
3
4
Licensee and/or Administrator to provide proof of correction to CCLD by 10/28/2023.
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 medications which poses an immediate health, safety or personal rights risk to persons in care. An open box of ClearLax was observed in the kitchen pantry.
POC Due Date:
10/28/2023
Plan of Correction
1
2
3
4
Licensee and/or Administrator to provide proof of correction to CCLD by 10/28/2023.
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
10/27/2023 02:45 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 medications that were not centrally stored, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/28/2023
Plan of Correction
1
2
3
4
Licensee and/or Administrator to provide proof of correction to CCLD by 10/28/2023.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews, the licensee did not comply with the section cited above in 1 of 1 instances which poses an immediate health, safety or personal rights risk to persons in care. An interview with staff informed the LPA that emergency drills are conducted on an annual basis as opposed to the required quarterly requirement.
POC Due Date:
10/28/2023
Plan of Correction
1
2
3
4
Licensee and/or Administrator to provide proof of correction to CCLD by 10/28/2023.
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
10/27/2023 02:45 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 observation and record review, the licensee did not comply with the section cited above in 1 out of 1 instances which poses an immediate health, safety or personal rights risk to persons in care. During the Annual inspection staff could not provide a copy of the Emergency Disaster Plan including plans for evacuation and fire safety.
POC Due Date:
10/30/2023
Plan of Correction
1
2
3
4
Licensee and/or Administrator to provide proof of correction to CCLD by 10/30/2023.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 instances which poses an immediate health, safety or personal rights risk to persons in care. The facility currently has 2 bedridden residents that it is not included in their license.
POC Due Date:
10/28/2023
Plan of Correction
1
2
3
4
Licensee and/or Administrator to provide proof of correction to CCLD by 10/28/2023.
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
10/27/2023 02:45 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87616(b)(1)
Exceptions for Health Conditions
(b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 7 instances which poses an immediate health, safety or personal rights risk to persons in care. This is evidenced by the fact that the facility could not provide documentation regarding one resident's current health condition.
POC Due Date:
11/03/2023
Plan of Correction
1
2
3
4
Licensee and/ or administrator to provide proof of correction to CCLD by 11/3/2023.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 6 bedrooms which poses an immediate health, safety or personal rights risk to persons in care. Bedroom 6 does not have an operating door alarm.
POC Due Date:
10/28/2023
Plan of Correction
1
2
3
4
Licensee and/or administrator to provide proof of correction by 10/28/2023.
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
6
of
7
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:
10/27/2023
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
26
27
28
29
30
31
32
Deficiencies of the California Code of Regulations, Title 22 are cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.
Two deficiencies were cited per California Code of Regulations, Title 22, see LIC 809-D. A civil penalty is being assessed for the amount of $500 (2x$250) for repeat violations regarding 87465(h)(2) and 87204(a). Licensee must submit plan of corrections by 10/28/2023.
As of October 27, 2023, the Department has yet received the plan of correction documents and facility was not able to provide it during today's visit. Due to deficiency
Section 87202(a) in the California Code of Regulations
not being corrected, a civil penalty is being assessed in the amount of $100 a day from 10/20/2023-10/27/2023. Failure to correct will result in additional civil penalties.
A copy of this report and appeal rights were provided. Acknowledgement of report is given to Caretaker, Alicia Lapuz.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
John Calandra
TELEPHONE:
650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
10/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
7
of
7