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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600928
Report Date: 08/23/2024
Date Signed: 08/23/2024 02:18:49 PM


Document Has Been Signed on 08/23/2024 02:18 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:TLC HOME CAREFACILITY NUMBER:
415600928
ADMINISTRATOR:BERNICE MAURICIO-ORMEFACILITY TYPE:
740
ADDRESS:7 HERMOSA LANETELEPHONE:
(650) 872-5006
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Josephine ManzanoTIME COMPLETED:
02:30 PM
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On 8/23/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Caregiver, Josephine Manzano, and explained the purpose of the visit.

A non-compliance conference was held on November 9, 2023. During non-compliance meeting, the following violations were discussed: Criminal Record Clearance, Emergency Drills, Administrator - Qualifications and Duties.

During the visit, LPA toured the facility and checked on residents. Some residents are being assisted with activities of daily living, some residents are currently resting in their respective rooms after having lunch. LPA reviewed the emergency drill in-service training, which happened last July 2024. All staff have criminal record clearance and are associated with the facility. Needs and service plan of residents are updated and current LIC500 was requested.

No citations issued today.

Report is reviewed with and a copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
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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