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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 05/03/2023
Date Signed: 05/15/2023 10:02:42 AM


Document Has Been Signed on 05/15/2023 10:02 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:
05/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Caregiver, M. VillonesTIME COMPLETED:
11:40 AM
NARRATIVE
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On May 3, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an annual visit made on 2/24/23. LPA met with Caregiver M.Villones and explained the purpose of the visit.

During an annual inspection conducted on 2/24/23, LPA Charitra cited the facility for Section 87305(a) Alterations to Existing Building or New Facilities, as a result of the facility altering the second floor without it being cleared by the fire department. The facility’s plan of correction was to submit a new facility floor plan to CCLD to request for a new fire clearance for the second floor.

On April 5, 2023, the San Mateo Fire Department conducted a fire inspection at the facility and denied the new fire request for the alteration of the second floor. According to the Fire Inspector, the construction on the 2nd floor is not to code and proper building permits will be required. In addition, the fire inspector indicated that there were no smoke alarms observed during the inspection.

During the visit today, LPA observed the second floor of the facility. LPA observed a total of 4 staff rooms and one bathroom on the second floor. Facility replaced the accordion doors with wooden doors. LPA to request a follow up fire clearance.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Caregiver M.Villones. Caregiver refused to sign -- a copy of the report is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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 2


Document Has Been Signed on 05/15/2023 10:02 AM - 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: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2023
Section Cited
CCR
87203

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87203 FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

Violation of this regulation is not met as evidenced by:
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Facility to submit an updated floor plan to LPA by 5/4/23. LPA will submit a follow up fire clearance request to the fire department for clearance.
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Based on observations and information collected, the licensee did not compy with the section cited above was not up to code and no smoke detectors was observed on the second floor. In addition the fire department indicated that prior to the alteration a proper building permit was required. Furthermore, the Licensee altered the facility's second floor, however was not cleared by fire department prior to alteration, which poses an immediate health, safety, or personal rights risk to persons in 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
LIC809 (FAS) - (06/04)
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