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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600340
Report Date: 06/30/2023
Date Signed: 06/30/2023 10:37:24 AM

Document Has Been Signed on 06/30/2023 10:37 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
SF COASTAL AC/SC, 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: 4DATE:
06/30/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, A. IsorenaTIME COMPLETED:
10:45 AM
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 June 30, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced health and safety case management visit. LPA met with Caregiver, A. Isorena and explained the purpose of the visit. LPA was screened at entry point by caregiver.

LPA toured the facility and ground. No accessible bodies of water of fire safety hazards observed. During the visit there were 4 residents observed watching television in the living room. This is a one story facility, with 2 resident bedrooms and 2 bathrooms. Residents rooms were observed to be shared rooms with beds 6ft apart from one another. Door alarms on the exit doors in both the resident bedrooms were in good working condition. Bathrooms were observed to be clean and odor free. LPA advised caregivers to avoid bar soaps. Liquid soaps and non-skid mats were present. According to the Caregiver, the facility does not put paper towels in the bathrooms due to resident's behaviors. Extra linen was observed to be present.

LPA toured the kitchen and observed medication and sharps to be locked and inaccessible to residents. 2-day perishable and 7-day non-perishable was observed. Living room was free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA toured the garage and observed additional food supply. Washer and dryer was observed to be in working condition and in good repair. There are two locked doors before entering the garage. The doors are locked at all times. Chemicals and toxins were observed in the locked garage. According to the caregiver, residents do not have access to the garage.

No deficiencies observed during this visit. LPA reviewed report with Caregiver and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
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 1