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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600340
Report Date: 01/24/2024
Date Signed: 01/24/2024 10:51:13 AM


Document Has Been Signed on 01/24/2024 10:51 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:
01/24/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Lilia MauricioTIME COMPLETED:
11:00 AM
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On 1/24/2024, Licensing Program Analyst (LPA), Murial Han conducted a Case Management visit to follow up on a plan of correction and the result from the recent fire inspection visit. LPA met with caregiver, Asuncion Isorena and administrator, Lilia Mauricio. LPA explained the purpose of today's visit.

The facility appeared to be cleaned and comfortable. There were 4 residents at the facility, 1 was watching TV in the living room, 2 were in bed and 1 was eating breakfast.

LPA discussed the observation that was made from the recent fire marshal inspection that the 2 shared rooms on the 1st floor appeared to be too small to accommodate 4 non-ambulatory residents. According to the administrator this concern was discussed with the fire marshal and the plan is to decrease the capacity from 4 to 3 as one of the female residents will be moving to one of the sister facilities tomorrow and then the facility rearrange resident rooms based on the recommendations provided by the fire marshal inspector.

LPA requested for documents to be submitted to CCL by 1/26/2024 to process capacity change: LIC 200, new facility sketch and a written notification to CCL of such change.

During today's meeting, LPA also requested for the following documents: plan of correction from the meeting that was held at the Regional Office on 11/9/2023 and the documents to change facility administrator: a written notification from the licensee appointing the new administrator, administrator certification, LIC 500, LIC 501, and LIC 308. These document shall be submitted to CCL by 1/26/2024.

No deficiencies observed during this visit. LPA reviewed report with caregiver and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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