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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600340
Report Date: 11/28/2023
Date Signed: 11/28/2023 12:21:12 PM


Document Has Been Signed on 11/28/2023 12:21 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 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:
11/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Assistant Administrator, Cirila MaricioTIME 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 November 28, 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow up on a decrease in capacity request that was submitted by the administrator in April 2021.

In April 1, 2021, administrator provided written notification to CCL that second floor of the facility will no longer be utilized as a facility for residents. In addition, facility has also submitted a copy of the LIC 200 to decrease the capacity.

During today's visit, LPA toured the second floor and observed living room, dinning room, kitchen, bathroom, master bed room with bathroom and closets, etc. LPA did not observe any residents and did not observe any evidence of care and supervision.

CCLD will be proceeding the request of decreasing in capacity from 6 (4 non-ambulatory and 2 ambulatory) to 4 non-ambulatory only on the first floor.

No deficiency cited today.

This report is reviewed and discussed with the assistant administrator.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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