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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 05/15/2023
Date Signed: 05/15/2023 10:25:47 AM


Document Has Been Signed on 05/15/2023 10:25 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:
05/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Caregiver, M. VillonesTIME COMPLETED:
10:37 AM
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On May 15, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced joint case-management visit with Fire Inspector, Jose Andrade with San Mateo Fire Department, to follow up on visits made by LPA on 2/24/23 and 5/2/23. LPA met with Caregiver, M. Villones and explained the purpose of the visit.

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.

On 4/5/23, Inspector Andrade, 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. According to the Licensee, on 4/12/23 changes were made to the second floor per Fire Inspectors recommendations.

On 5/3/23, LPA cited the facility for Section 87203 Fire Safety, as a result of the Licensee altering the second floor of the facility prior to obtaining a new fire clearance from the Fire Department. The Licensee was to submit a new floor plan to LPA by 5/4/23 after making the necessary changes, however LPA did not receive the floor plan. Due to the citation 87203 Fire Safety, not being corrected by 5/4/23, a civil penalty is being assessed in the amount of $100 a day from 5/5/23 through 5/15/23 and will continue to accrue until corrected. A civil penalty of $1,100 is being assessed today.

During the visit today, LPA and Inspector Andrade inspected the first floor and second floor of the facility. According to the Fire Inspector, the first floor of the building is in compliance, however the second floor construction requires proper building permits.

No citations are issued during this time. Report is reviewed with Caregiver and a copy is provided. A copy of civil penalty is provided with appeal 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: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
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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