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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:15:44 PM


Document Has Been Signed on 06/20/2023 03:15 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:
06/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Caregiver M.VillonesTIME COMPLETED:
03:30 PM
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On June 20, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on the visit conducted on 6/16/2023. LPA met with Caregiver, M.Villones and explained the purpose of the visit.

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. According to code enforcement officer, the office area is a non-habitable space and should not be used for sleeping purposes.

During the visit, LPA observed staff members utilizing the bedroom on the second floor to accommodate 4 live-in staff. In addition, LPA observed the second floor office area that had constructed makeshift walls to be partly removed, however two beds were observed in the second floor hallway and one staff was observed sleeping on the bed located in the hallway.

According to the caregiver, the facility is still working on removing the walls and the beds and will be done by today.

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.

Report is reviewed with Caregiver and a copy 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: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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Document Has Been Signed on 06/20/2023 03:15 PM - 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: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2023
Section Cited
CCR
87305(a)

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87305 Alterations to Existing Building or New Facilities: (a) Prior to construction or alterations, all facilities shall obtain a building permit.

Violation of this regulation is not met as evidenced by:
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Licensee shall submit a plan in writing to obtain a proper building permit prior to construction and alterations.
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Based on observations conducted, facility has installed makeshift walls in the open office area on the second floor without a proper building permit. In addition, on 6/1/23 San Mateo Code Enforcement Officer inspected the facility and indicated that there were violations observed and the facility office area on the second floor is non-habitable and should not be used for sleeping purposes.
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A civil penalty in the amount of $250.00 is being assessed for repeat violation within the last 12 months. Facility was cited on 2/24/2023.
Type A
06/21/2023
Section Cited
CCR87307(a)(2)(B)

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87307 Personal Accommodations and Services: (a) ... The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff...who may reside in the facility...(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements...(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.

Violation of this regulation is not met as evidenced by:
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Licensee to submit a plan in writing to address how to provide habitable living accommodations for staff until proper fire clearance has been obtained.
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Based on observations, LPA observed two beds located in the office area on the second floor of the hallway. Staff was observed to be sleeping on one of the beds located on the second floor of the hallway
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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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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