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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600340
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:28:50 PM


Document Has Been Signed on 11/09/2023 03:28 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 CAREFACILITY NUMBER:
415600340
ADMINISTRATOR:MAURICIO, LILIAFACILITY TYPE:
740
ADDRESS:40 SHELTER CREEK LANETELEPHONE:
(650) 952-1687
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: DATE:
11/09/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lilia Maurico & Jason PinedaTIME COMPLETED:
03:30 PM
NARRATIVE
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On November 9, 2023, San Bruno Regional Office conducted a non-compliance conference meeting with Licensee, Lilia Mauricio & Administrator Jason Pineda.

Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Managers, Cara Smith and April Cowan, Licensing Program Analysts, Grace Donato, Audrey Jeung and John Calandra. Long Term Care Ombudsman, Robert Lewetzon was also present in this meeting.
 
During non-compliance meeting, the following violation was discussed, Care of Persons with Dementia.

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.  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

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 a copy of this report and the Appeal Rights are provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
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)
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Document Has Been Signed on 11/09/2023 03:28 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
FACILITY NUMBER: 415600340

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)

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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.
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Plan of correction to be submitted to CCLD BY DUE DATE, in which licensee shall ensure that facility operates in conformance with these regulations
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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.
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Type A
11/13/2023
Section Cited
HSC1569.58(a)(2)

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Persons prohibited from being a licensee...(2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.
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The Licensee shall comply with the regulation stated herewithin and other agencies of such a change in the future. A written statement of such shall be received by the POC date stated.
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This H&S regulation has not been met as evidenced by: The licensee is currently providing unlicensed care to another facility which jeopardized the residents' health and safety and the care and supervision of the residents in care.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
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 2