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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600454
Report Date: 11/09/2023
Date Signed: 11/09/2023 04:15:42 PM


Document Has Been Signed on 11/09/2023 04:15 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:
11/09/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lilia Mauricio, Licensee and Jason Pineda, Administrator TIME COMPLETED:
04:15 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 November 9, 2023, San Bruno Regional Office conducted a non-compliance conference meeting with
Licensee, Lilia Mauricio and Jason Pineda, Administrator at TLC Home Care II.

Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Managers, Cara Smith
and April Cowan, Licensing Program Analysts, Audrey Jeung, Grace Donato, and John Calandra .
Long Term Care Ombudsman, Bob Lewetzon was also present in this meeting.

During non-compliance meeting, the following violations were discussed: General Food Service Requirements, Reappraisals, Storage Space, Incidental Medical and Dental Care, Postural Supports, Care of Persons with Dementia, Exceptions for Health Conditions, Emergency Disaster Plan, Emergency Plans, Fire Clearance, Maintenance and Operations, Care of Bedridden residents.

During this meeting, the following citations were amended:
-Incidental and Medical Dental from a Case Management visit that was conducted on 11/7/2023
-Postural Support from a Case Management that was conducted on 10/18/2023.

The following citations were removed:
-Limitations on Capacity/Ambulatory Status which was cited on 10/18/2023
-Alterations to Existing buildings or new facilities which was cited on 10/4/2023

During this meeting, it was discussed, Community Care Licensing will increase frequency monitoring
inspection visits to ensure compliance with this compliance plan of Title 22 regulation.

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 reviewed with Licensee/Administrator, Lilia Mauricio and Jason Pineda and a copy of this report and the Appeal Rights are provided.

Licensee was provided the link below for resources and guidance to improve facility operations:

https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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 3


Document Has Been Signed on 11/09/2023 04:15 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: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2023
Section Cited
CCR
87205(a)

1
2
3
4
5
6
7
Accountability of Licensee Governing Body: The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
1
2
3
4
5
6
7
Plan of correction to be submitted to CCLD BY DUE DATE, in which licensee shall ensure that facility operates in conformance with these regulations
8
9
10
11
12
13
14
This requirement was not met , as licensee failed to operate facility in conformance with regulations, which poses an immediate health, safety, or personal rights risk to clients in care.
8
9
10
11
12
13
14
Type A
11/13/2023
Section Cited
CCR87405(h)

1
2
3
4
5
6
7
ADMINISTRATOR--QUALIFICATIONS/ DUTIES
The administrator shall have the responsibility to administer the facility in accordance with these regulations and established policy, program, and budget.
This requirement is not met, as administrator
1
2
3
4
5
6
7
Licensee shall develop a plan of action and submit to CCLD BY , which will include how the administrator shall perform the duties and requirements according to regulations.
8
9
10
11
12
13
14
failed to adhere to local ordinances on building construction, fire safety, and licensing requirements when facility retained bedridden residents. This posed an immediate health, safety, or personal rights risk to residents in care. Furthermore, in interviews with the administrator, they acknowledged a lack of knowledge regarding their infection control plan and practices.
8
9
10
11
12
13
14
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: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/09/2023 04:15 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: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2023
Section Cited
CCR
87606(f)

1
2
3
4
5
6
7
Care of Bedridden Residents: To accept or retain a bedridden person, a facility shall ensure the following: The facility's plan of operations shall include a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons.
1
2
3
4
5
6
7
Licensee and/or Administrator to provide written proof of correction to the department by 11/13/2023.
8
9
10
11
12
13
14
Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to residents. The facility currently has 2 bedridden residents in their 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: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3