Community Care Licensing

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023

Document Has Been Signed on 12/14/2023 01:31 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/07/2023 02:14 PM

FACILITY NAME: TLC HOME CARE II	FACILITY NUMBER: 385600454
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	8 9 10 11 12 13 14	**This report was amended to remove a previous deficiency related to limitations and capacity. **	8 9 10 11 12 13 14
Type A 10/18/2023 Section Cited CCR87608(a)(5)(B)	1 2 3 4 5 6 7	POSTURAL SUPPORTS Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as client in room 5 on ground level uses	1 2 3 4 5 6 7	Full bed rail will be removed or shortened by DUE DATE, and plan/proof of correction to be sent to CCLD BY DUE DATE. Half bed rail may be utilized only if there is an MD order maintained for half bed rail.
	8 9 10 11 12 13 14	full bed rail. Client is not receiving hospice services. Licensee failed to ensure that full bed rails are only used for hospice residents, which poses an immedialte health, safety or personal rights risk to clients in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023

Document is an Amendment of Original Document on 11/09/2023 11:59 AM

FACILITY NAME: TLC HOME CARE II	FACILITY NUMBER: 385600454
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/19/2023 Section Cited CCR 87608(a)(2)	1 2 3 4 5 6 7	POSTURAL SUPPORTS Postural supports shall be fastened or tied in a manner that permits quick release by the resident. This requirement is not met, as client in room 5 is observed seated in wheelchair in living room, with beige gait belt around her waist	1 2 3 4 5 6 7	Plan/proof of correction to be sent to CCLD BY DUE DATE
	8 9 10 11 12 13 14	and wheelchair, with buckle in back. Licensee failed to ensure that postural support is fastened in front, so client can easily unfasten it. This poses an immediate health, safety, or personal rights risk to clients in 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

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023

Document Has Been Signed on 10/18/2023 06:16 PM - It Cannot Be Edited

FACILITY NAME: TLC HOME CARE II	FACILITY NUMBER: 385600454
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/25/2023 Section Cited CCR 87307(a)(2)(C)	1 2 3 4 5 6 7	PERSONAL ACCOMMODATIONS/SVCS No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met, as administrator "office" is accessed from room #4 on upper level. This "office" appears to be a large closet. Licensee failed to ensure that	1 2 3 4 5 6 7	Desk, chair and other facility operations materials will be removed from closet of room #4 and will not be used by staff. Plan/proof of correction will be sent to CCLD BY DUE DATE.
	8 9 10 11 12 13 14	bedrooms are not passageways to another room, which poses a potential health, safety or personal rights risk to clients in 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

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023