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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600831
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:55:37 PM


Document Has Been Signed on 11/09/2023 03:55 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: DATE:
11/09/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lillie MauricioTIME COMPLETED:
04:00 PM
NARRATIVE
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On November 9, 2023, San Bruno Regional Office conducted a non-compliance conference meeting with Licensee/Administrator, Lilia Mauricio.

Present in the meeting are Regional Manager, Vivien Helbling, Licensing Program Managers, Cara Smith, Jackie Jin, and April Cowan, Licensing Program Analysts, Grace Donato, Audrey Jeung and John Calandra, Long Term Care Ombudsman, Robert Lewitzon and Alan Kornfield are also present in this meeting.
 
The following violations are discussed: Alterations to Existing Building or New Facilities, Personal Accommodations and Services, Fire Safety, Criminal Record Clearance, Storage Space, and Care of Persons with Dementia.

Community Care Licensing will increase frequency of monitoring inspection visits to ensure compliance with Title 22 regulations and this compliance plan. Licensee is provided the link below for resources and guidance to improve facility operations: 
  
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers

Deficiencies of the California Code or Regulations, Title 22, are cited on a following page.


Report was reviewed with Licensee/Administrator, Lilia Mauricio and copies are provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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 3


Document Has Been Signed on 11/09/2023 03:55 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: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2023
Section Cited
CCR
87205(a)

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ACCOUNTABILITY OF LICENSEE GOVERNING BODY
The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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Plan of correction to be submitted to CCLD BY DUE DATE, in which licensee shall ensure that facility operates in conformance with these regulations
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This requirement was not met , as licensee failed to operate facility in conformance with regulations, which poses an immediate health, safety, or personal rights risk to clients in care.
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Type A
11/13/2023
Section Cited
CCR87405(h)(1)

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ADMINISTRATOR--QUALIFICATIONS/ DUTIES
The administrator shall have the responsibility to administer the facility in accordance with these regulations and established policy, program and budget.
This requirement is not met, as administrator
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Licensee shall develop a plan of action and submit to CCLD BY DUE DATE, which will include how the administrator shall perform the duties and requirements according to regulations
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failed to adhere to local ordinances on building construcion, fire safety, and licensing requirements when building was altered. This posed an immediate health, safety, or personal rights risk to clients in care.
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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: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/09/2023 03:55 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: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2023
Section Cited
HSC
1569.58(a)(2)

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HEALTH AND SAFETY CODE
The Dept. may prohibit any person from being a licensee, owning a beneficial ownership interest of 10 % or more in a licensed facility, or being an administrator... licensee...and who has done any of the following: Engaged in conduct that is inimical
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The licensee shall comply with the regulation stated herewithin and other agencies of such a change in the future. A written statement of such shall be received by the POC date stated.
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to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of CA. This H&S regulation has not been met as licensee is currently providing unlicensed care to another facility which jeopardized the health, safety and care and supervision of residents in care.
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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: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
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