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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:38:38 PM


Document Has Been Signed on 02/24/2023 01:38 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 CARE IIIFACILITY NUMBER:
415600831
ADMINISTRATOR:MAURICIO, LILIA L.FACILITY TYPE:
740
ADDRESS:630 VANESSA DRIVETELEPHONE:
(650) 638-0359
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 6DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Caregiver, Matina KayasthaTIME COMPLETED:
01:48 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 February 24, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA met with Caregiver, Matina Kayastha and explained the purpose of the visit. LPA was screened at entry point and caregiver was able to provide LPA screening log documentation for staff, visitors, and residents.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a double story home; second story designated for live-in staff. LPA toured the first floor and observed 6 resident bedrooms; all of which are private rooms. LPA observed 4 full bathrooms to be clean, odor free, and equipped with liquid soap, paper-towels, hand-washing signs, and a trash can with a fitted lid. Non-skid mats were present in showers. Extra linen was observed. During the visit, LPA observed 4 resident rooms with door alarms going from the bedrooms to outside the facility to not be in working condition. According to the Caregiver, the residents do have dementia.

LPA observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 72 degrees F is maintained and lighting is sufficient for comfort. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable, Sharps drawer was observed to be unlocked. Caregiver locked the drawer during the time of visit. LPA observed medications to be locked and inaccessible to residents in care. LPA advised caregiver to remove all hand-towels from the kitchen. LPA toured the garage and observed extra food supply present. Washer and dryer was observed to be in good repair. LPA observed chemicals and toxins cabinet to be unlocked. Caregiver immediately locked the cabinet in LPA's presence. Facility was unable to show LPA 30-day PPE supply.

LPA toured the second floor of the facility and observed the staff bathroom to be clean and in good repair. LPA observed that the office room on the second floor (noted on the facility sketch) altered into 3 private staff rooms.

CONT. to 809C
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE III
FACILITY NUMBER: 415600831
VISIT DATE: 02/24/2023
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
26
27
28
29
30
31
32
During the visit, LPA observed two staff members, Staff 1 (S1) and Staff 2 (S2) providing care to the residents, however was not fingerprinted and/or associated to the facility. LPA reviewed personnel files and observed S1 and S2 to have fingerprint clearance. The facility submitted fingerprint transfer for S1 as observed in S1's file, however LPA did not observe fingerprint transfer for S2.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

LPA requests the following forms to be submitted to CCLD by 2/28/23:
-LIC308 Designation of Administrator Organization
-LIC500 Personnel Report
-LIC610D Emergency Disaster Plan
-Administrator Certificate

Report is reviewed with Caregiver and copy is provided with appeals rights. Caregiver refused to sign.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/24/2023 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE III
FACILITY NUMBER: 415600831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2023
Section Cited

1
2
3
4
5
6
7
87355 Criminal Record Clearance: (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another... by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to submit LIC9182 to CCL or LPA by 2/25/23.

An immediate civil penalty of $100 will be assessed during the visit.
8
9
10
11
12
13
14
Based on record review, it was noted that S2 does have fingerprint clearance, however was not associated to the facility.
8
9
10
11
12
13
14
Type A
02/25/2023
Section Cited

1
2
3
4
5
6
7
87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons...which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
Caregiver immediately locked the toxins in LPA's presence. Licensee/ Administrator to conduct an in-service training regarding locking of toxins and chemicals
8
9
10
11
12
13
14
During the visit, LPA observed that the chemicals and toxins cabinet located in the garage was unlocked and accesible to residents which poses an immediate health and safety risk to residents in care
8
9
10
11
12
13
14
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/24/2023 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE III
FACILITY NUMBER: 415600831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2023
Section Cited

1
2
3
4
5
6
7
87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives... and other items that could constitute a danger to the resident(s).

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to send LPA a copy of receipt for new lock and to send LPA copy a photo of the LOCKED knives drawer by 2/25/23. Sharps will me removed an locked in another location till lock is replaced.
8
9
10
11
12
13
14
During the visit, LPA observed the knives drawer to be unlocked which poses an immediate health and safety risk to residents in care,
8
9
10
11
12
13
14
Type A
02/25/2023
Section Cited

1
2
3
4
5
6
7
87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to replace and ensure all door alarms are working and to provide LPA with a video to show the alarms are working.
8
9
10
11
12
13
14
During the visit, LPA observed 4 out of 6 of the resident rooms with door alarms leading from their bedroom to the outside of the facility, to not be working.
8
9
10
11
12
13
14
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5


Document Has Been Signed on 02/24/2023 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE III
FACILITY NUMBER: 415600831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited

1
2
3
4
5
6
7
87305 Alterations to Existing Building or New Facilities:
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

Violation of this regulation is evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to submit a new floor plan to LPA indicating the change from office room to staff room. LPA to submit for a new fire clearance.
8
9
10
11
12
13
14
During the visit, LPA observed the second floor office room to be altered into 3 private staff bedrooms which was not cleared by the fire department or on the facility sketch.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5