<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 07/24/2023
Date Signed: 07/24/2023 11:10:54 AM

Document Has Been Signed on 07/24/2023 11:10 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: DATE:
07/24/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Lilia MauricioTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On July 24, 2023, Regional Manager (RM) Vivien Helbling, Licensing Program Manager (LPM) Cara Smith, and Licensing Program Analyst (LPA) Komal Charitra met with the facility Licensee, Lilia Mauricio to discuss the serious violations that has been addressed and actions taken by the Licensee regarding altering the facility without approval from Fire Department and San Mateo County Building Department for facility TLC Care Home III.

During today's office meeting the serious violations, plan for live-in staff, and pending penalties were discussed. In addition, LPM Smith requested copies of updated documents for all four of Licensee’s facilities.

Licensee to submit the following:
-LIC500 Personnel Report for all 4 facilities
-LIC308 Designation of Administrative Responsibility for all 4 facilities
-Control of Property
-Updated administrator documents

RO will refer the facility to the Department’s technical support program (TSP). Report is reviewed with Licensee and a copy is provided. No citations were issued today.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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 1