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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600808
Report Date: 08/10/2019
Date Signed: 08/10/2019 01:20:24 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:ALWAYS TLCFACILITY NUMBER:
415600808
ADMINISTRATOR:CONSUNJI, TOMASFACILITY TYPE:
740
ADDRESS:226 SANDPIPER COURTTELEPHONE:
(650) 345-1441
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:6CENSUS: 6DATE:
08/10/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Adoracion MoresTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and was met by caregiver Adoracion Mores and Alvin Gomez. Administrator (out of town) was informed by LPA via telephone about the purpose of visit. administrator authorized Mores to sign the final evaluation report.

LPA inspected the facility inside and out including but not limited to resident rooms, living room, bathrooms, kitchen, dining area and backyard. Passageways and hallways were observed free of obstruction. Three residents were observed up in the living room watching television, reading newspaper and one was on her cellphone. There was sufficient supply of perishable foods observed. Hot water in the common bathroom measured at 117 degrees Fahrenheit. There was sufficient supply of linen, blankets, towels and hygiene products observed. Bath/shower rooms were observed with grab bars and non skid mats. First aid kit was complete. LPA observed a fire extinguisher in the kitchen that appeared full but there was no tag to show last inspection date.

While conducting physical plant inspection, LPA observed the following:

1. Comet bleach unlocked under kitchen sink
2. Lysol spray insecticide observed unlocked under sink in bathroom
3. Room #4 designated as staff room in facility sketch is being used as resident room
4. staff room was constructed in the garage and was previously cited on 2/12/18 LPA but has
has not been cleared by facility as of 7/2019

*****continuation on Lic 809C*****
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2019
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ALWAYS TLC
FACILITY NUMBER: 415600808
VISIT DATE: 08/10/2019
NARRATIVE
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At 11 am, LPA reviewed 3 resident files and 3 staff files. L PA observed S1 does not have current first aid and CPR on file and S2 does not have TB test/skin test on file. LPA was not able to verify staff training because the proof of training do not indicate number of hours completed.

Deficiencies were cited per Title 22 California Code of Regulations. Please refer to Lic 809 D.

Exit interview conducted with Administrator via telephone; Appeal Rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ALWAYS TLC
FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2019
Section Cited
CCR
87204(b)
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Limitations - Capacity and Ambulatory Status
Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.


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Within 24 hours, Administrator will notify local fire department about R2 occupying Room 4. By 8/13/19, Administrator will submit to CCL Lic 200 and updated facility sketch.

civil penalty of $500 for fire clearance violation is assessed
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This requirement is not met as evidenced by:
Based on observation and verification made with Administrator, Room 4 has fire clearance as staff room. However, Room 4 is being occupied by R2 who is nonambulatory which poses an immediate risk to health and safety of clients under care.
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Type A
08/23/2019
Section Cited
CCR
87309(a)
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Storage Space
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Caregiver locked Comet and Lysol in the presence of LPA;deficiency cleared
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Based on observation, facility failed to lock Comet under kitchen sink and Lysol spray under bathroom sink which poses an immediate risk to health and safety of clients under 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ALWAYS TLC
FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2019
Section Cited
CCR
87555(26)
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General Food Service Requirements
Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
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By POC date, Administrator will send photo proof and proof of purchase of additional non perishable foods.
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Based on observation, facility failed to maintain 7-day supply of non perishable foods which poses a potential risk to health and safety of clients.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ALWAYS TLC
FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2019
Section Cited
CCR
87305(a)
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ALTERATIONS TO BUILDINGS & GROUNDS
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:

Based on information obtained from Administrator,
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By POC date, Administrator will provide CCL status update and plan in regards to the request for clearance for room in the garage,
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there is no proof that there is an approved building permit for staff room in garage. Licensee failed to maintain approved building permit for room in garage for staff, which poses a potential risk to health and safety of clients.
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Type B
08/16/2019
Section Cited
CCR
87411(c)(1)
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Personnel Requirements - General
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Based on file review conducted, facility to make sure that S1 has current first aid/CPR which poses a potential risk to clients.
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By POC date, Administrator will send to CCL a copy of S1's current first ad and CPR.
Type B
08/16/2019
Section Cited
CCR
87411(f)
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Personnel Requirements - General
Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment.....
S2 does not have proof of TB test/skin test on file.
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By POC date, Administrator will send to CCL proof of TB/skin test result for S2.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5