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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 06/16/2023
Date Signed: 06/16/2023 12:11:17 PM


Document Has Been Signed on 06/16/2023 12:11 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:
06/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Caregiver, M. MalupaTIME COMPLETED:
12:20 PM
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On June 16, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an inspection made on 6/1/2023. LPA met with Caregiver, M. Malupa and explained the purpose of the visit.

During an annual inspection on 2/24/2023, LPA observed that the second floor facility to be altered. Based on the floor plan and fire clearance, it was noted that the facility was cleared for one office room and one bathroom on the second floor. However, during the visit, LPA observed three compartment/rooms that were built for live-in staff members, in addition to the office room and the bathroom. Based on information collected during the visit, the facility did not have a fire clearance for the three constructed compartment/rooms on the second floor.

On 6/1/2023, LPA Charitra, San Mateo Fire Inspector Jose Andrade and San Mateo Code Enforcement Officer, John Freitas conducted an inspection of the altered second floor of the facility to verify code violations exist.

On 6/13/2023, Code Enforcement Officer notified CCL and Licensee in relation to the violations that were observed during the inspection made on 6/1/2023. Code Enforcement Officer inspected the altered area and found three violations present during inspection. Code Enforcement Officer requested facility to comply by 6/27/2023.

During the visit today, LPA observed the second floor of the facility and observed the constructed area to still be present. Staff are observed to still be living in the rooms. Interviewed staff indicated that they are not aware of further plans regarding the second floor. LPA Charitra is still awaiting Licensee's plan for the alterations made on the second floor.

--Licensee to submit LPA an updated control of property by 6/17/2023.

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: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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