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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 01/22/2024
Date Signed: 01/22/2024 12:42:28 PM


Document Has Been Signed on 01/22/2024 12:42 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: 1DATE:
01/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Bernice Mauricio-OrmeTIME COMPLETED:
01:00 PM
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On January 22, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on the plan of correction that was presented to the Licensee on 11/9/2023. LPA met with Administrator, Bernice Mauricio-Orme and explained the purpose of the visit.

On 11/9/2023, a non-compliance conference was held at the San Bruno Regional Office. Licensee, Lilia Mauricio was present during the meeting. During the meeting, previous facility deficiencies were reviewed and a compliance plan was presented to the Licensee.

During the visit, LPA toured the facility and grounds. LPA observed chemicals, toxins, sharps all locked and inaccessible. Medications were observed locked. 7-day non- perishables and 2 day perishables were observed present. 2nd floor of the facility was clear and free from obstruction. Door alarms were observed to be in good working condition.

In addition, during the visit, LPA observed only one resident present. According to the Administrator, the other 5 residents were discharged due to plumbing repairs. Facility provided notices to resident's families and notified CCL regarding resident's moving.

Overall facility is in compliance with compliance plan that was presented to Licensee on 11/9/2023. No deficiencies are cited during this visit.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
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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