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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 06/29/2023
Date Signed: 06/29/2023 01:15:28 PM


Document Has Been Signed on 06/29/2023 01:15 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:
06/29/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Caregiver, M. Malupa TIME COMPLETED:
01:30 PM
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On June 29, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citations that were issued on 6/20/2023. LPA met with Caregiver, M. Malupa and explained the purpose of the visit.

LPA toured the second floor of the facility and observed the constructed areas to be torn down and converted back to the original floor plan that was initially approved by San Mateo Fire Department. LPA did not observe any beds in the hallway on the second floor. Staff are sleeping in the staff bedroom located upstairs.

Plan of correction has been verified and deficiencies that were cited on 6/20/2023 have been cleared.

LPA will submit a new updated fire clearance inspection.

No deficiencies cited during this visit. LPA reviewed report 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: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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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