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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600340
Report Date: 10/14/2023
Date Signed: 10/17/2023 09:37:50 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/17/2023 09:37 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
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: 4DATE:
10/14/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Asuncion IsorenaTIME COMPLETED:
11:30 AM
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Unannounced annual visit made out to this facility on 10/14/2023 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility caregiver, Asuncion Isorena, who was requested by this LPA to go ahead and contact the facility Licensee/Administrator to inform him/her that CCL was present at this time.
The facility caregiver stated that the Licensee was not feeling well at this time and was self-isolating from the facility residents and staff.
Current census was 4 residents.
It was learned that an annual visit had already been completed on 10/11/2023 by an LPA hailing from the San Bruno office.
A copy of the report was requested by this LPA for this annual visit that had already been completed. The facility caregiver did produce a copy of the LIC 809, dated and signed on 10/11/2023, for an annual visit.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2023
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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