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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600340
Report Date: 10/17/2024
Date Signed: 10/17/2024 05:49:36 PM

Document Has Been Signed on 10/17/2024 05:49 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/
DIRECTOR:		CIRILA G. MAURICIOFACILITY TYPE:
740
ADDRESS:40 SHELTER CREEK LANETELEPHONE:
(650) 952-1687
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 3CENSUS: 0DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver, Asuncion J. IsorenaTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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On October 17, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Asuncion J. Isorena and LPA explained the purpose of the visit.

LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 2 private rooms. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient; full bathroom was observed clean and in operating condition. Comfortable temperature is maintained and lighting is sufficient for comfort
Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.

Hot water temperature in the kitchen and bathroom were measured at 106-110 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 8/9/2023.

During today's visit, there was no resident present as the previous residents were discharged and the Licensee is seeking for new admission.

A review of (1) staff files was conducted and noted on the LIC 859.

No deficiency is cited today; this report is reviewed and discussed with the caregiver.

A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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