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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600928
Report Date: 03/04/2024
Date Signed: 03/04/2024 05:54:42 PM


Document Has Been Signed on 03/04/2024 05:54 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:MAURICIO, LILIA L.FACILITY TYPE:
740
ADDRESS:7 HERMOSA LANETELEPHONE:
(650) 872-5006
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 5DATE:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Bernice Mauricio-OrmeTIME COMPLETED:
04:00 PM
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On 3/4/2024 Licensing Program Analyst (LPA) Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Bernice Mauricio-Orme. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including resident rooms, common areas, garage & bathrooms. The indoor and outdoor passageways were free of obstruction. The residents have adequate amount of linens in their bedrooms. All personal belongings are intact. While touring the facility it was observed that the room temperature was at 71 deg F. Bathroom water temperature is at 112 deg F. Resident bedrooms and bathrooms were observed to be in good repair. Bathrooms are equipped with grab bars and non-skid floors and mats. Carbon monoxide monitor are working properly. All fire extinguishers have been checked and current. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Sharps and chemicals are locked and inaccessible to residents. Emergency drill is done quarterly.

Medication are locked and centrally stored medications are updated.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements.

No citations issued today. Report is reviewed with and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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