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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600340
Report Date: 01/21/2021
Date Signed: 02/04/2021 09:33:30 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:TLC HOME CAREFACILITY NUMBER:
415600340
ADMINISTRATOR:MAURICIO, LILIAFACILITY TYPE:
740
ADDRESS:40 SHELTER CREEK LANETELEPHONE:
(650) 952-1687
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 3DATE:
01/21/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cirila MauricioTIME COMPLETED:
12:00 PM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted a Case Management tele-visit to provide Technical Assistance (TA) to the facility regarding COVID-19 with the assistance from Irene Thibault, RN of the California Department of Public Health. The tele-visit was conducted with Cirila Mauricio, co-administrator.

According to Cirila, the staff and residents who tested positive for COVID-19 have completed their isolation. The previous mass testing was conducted on January 12, 2021 and all test results were negative. No set schedule has been confirmed for COVID-19 vaccination at the moment.

The TA tele-visit resulted with the following recommendations:
- Screen for additional COVID-19 symptoms as described in PIN 20-07 and document the screening process. (provided)
- Remove extra chairs: 2 from dining table and chairs at the sunroom.
- Continue to disinfect trash cans after each use.
- If disinfectant wipes are not available: mix 5 tbsp of Clorox with 1 gallon of water.
- Please communicate with CVS or Walgreens to confirm COVID-19 vaccination schedule. (email contacts provided)

Licensee is to ensure to submit a signed and dated action plan regarding the above recommendations to LPA, via email, within 24 hours.

Report was reviewed and discussed with Cirila at the end of visit. An electronic copy of the report was emailed to licensee for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
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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