415600340-10-11-2023-14-AS-MHAN-CWHQQS-20231011122250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600340
Report Date: 10/11/2023
Date Signed: 10/11/2023 06:24:42 PM

Document Has Been Signed on 10/11/2023 06:24 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	TLC HOME CARE		FACILITY NUMBER:	415600340
ADMINISTRATOR:	MAURICIO, LILIA		FACILITY TYPE:	740
ADDRESS:	40 SHELTER CREEK LANE		TELEPHONE:	(650) 952-1687
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 4	DATE:	10/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Caregiver, Asuncion Isorena		TIME COMPLETED:	12:30 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 October 11, 2023 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Asuncion Isorena and LPA explained the purpose of the visit. 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. The facility observed to clean, tidy and in good repair. Bedrooms are equipped with required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 101- 107 degrees F. Central stored medication were observed to be locked and inaccessible to residents. Food supplies were observed to be adequate, At 10:35AM, LPA observed sharps in the kitchen was unlocked and at 10:45AM, LPA observed chemicals in the kitchen underneath the kitchen sink and chemicals in the laundry were unlocked. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced August 13, 2023. In regards to facility drills, facility was not able to provide documents that they were completed.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 415600340
	VISIT DATE: 10/11/2023

NARRATIVE

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LPA reviewed 4 residents records and all of them contained identification and emergency information, admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, etc.

LPA reviewed 3 staff files and all of them contained personnel records, health screening, job description, training records, First Aide and CPR, criminal record clearance and all 3 staff are associated.

Facility does not handle resident's P & I.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with caregiver, Asuncion Isorena. A copy of this report and Appeal Rights were provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/11/2023 06:24 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TLC HOME CARE	FACILITY NUMBER: 415600340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above as LPA observed chemicals were not locked in the kitchen and the laundry room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure chemicals are locked and inaccessible to residents at all times. The plan shall include staff training. The administrator will provide a copy of the plan and a copy of the staff training sign-in sheet to CCL by 10/12/2023.

Type A

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record reviews, the licensee did not comply with the section cited above as the facility was not able to provide proof that drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure drills are completed accordingly. The plan shall include staff training. The administrator will provide a copy of the plan and a copy of the staff training sign-in sheet to CCL by 10/12/2023.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/11/2023 06:24 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TLC HOME CARE	FACILITY NUMBER: 415600340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above as the facility failed to lock the sharp drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure sharps are locked and inaccessible to residents at all times. The plan shall include staff training. The administrator will provide a copy of the plan and a copy of the staff training sign-in sheet to CCL by 10/12/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC809 (FAS) - (06/04)

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