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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 03/08/2023
Date Signed: 03/08/2023 10:19:50 AM


Document Has Been Signed on 03/08/2023 10:19 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 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:
03/08/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Annaliza FranciaTIME COMPLETED:
10:29 AM
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On March 8, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced Plan of Correction (POC) visit to verify and to confirm that the facility is in compliance with the citations that were issued on 2/24/23. LPA Charitra met with Caregiver, Annaliza Francia and Mary Villones and explained the purpose of the visit.

On 2/24/23, facility was cited for the following citations: California Code of Regulation (CCR), 87355(c)(1) Criminal Record Clearance, 87309(a) Storage Space, 87305(a) Alterations to Existing Building or New Facilities, 87705(f)(1) Care of Persons with Dementia, and 87705(j) Care of Persons with Dementia.

During the visit conducted today, LPA toured the facility and reviewed the plan of corrections submitted to LPA. LPA observed all 6 resident rooms with new door alarms installed and observed them all to be in working condition. All toxins, chemicals, and sharps were locked and stored appropriately and inaccessible to residents. The deficiencies cited on 2/24/23 are cleared.

No citations are issued at this time. Report is reviewed with caregiver and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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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