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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 11/07/2023
Date Signed: 11/09/2023 10:40:42 AM


Document Has Been Signed on 11/09/2023 10:40 AM - 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:
11/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Nieves Sulayao, CaregiverTIME COMPLETED:
06:30 PM
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On November 7, 2023, Licensing Program Analysts (LPA) John Calandra and Audrey Jeung conducted an unannounced plan of correction (POC) visit to clear deficiencies cited during an Annual inspection made on October 27, 2023. LPAs Calandra and Jeung met with Nieves Sulayao, caregiver, and explained the purpose of their visit.

LPAs Calandra and Jeung toured bedroom 5 on the first floor, downstairs and observed Nieves Sulayao, caregiver open the door to the outside and heard an audible alarm. LPAs Calandra and Jeung observed all medications to be locked up and inaccessible to persons in care in the kitchen. The facility submitted a copy of the 610e-Emergency and Disaster Plan on November 4, 2023, and a letter stating that all staff had completed a emergency drill on October 30, 2023.

Deficiency 87616(b)(1)-Exceptions for Health Conditions and still exist, as plan/proof of correction has not been received by the department.

On 11/7/2023, LPA Calandra and LPA Jeung observed proof of correction. Acknowledgement of corrections is given to caregiver--1 page.

Civil Penalty of $1000($100 per day x10 days) is hereby assessed for the period of October 28,2023 to November 6, 2023 for failure to correct deficiency 87204-Fire Safety. Administrator submitted Plan of Correction on November 7, 2023. See LIC421FC and POC letter.

Report is reviewed with Administrator and copies are provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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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