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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600928
Report Date: 11/21/2024
Date Signed: 11/21/2024 04:14:20 PM

Document Has Been Signed on 11/21/2024 04:14 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/
DIRECTOR:		BERNICE MAURICIO-ORMEFACILITY TYPE:
740
ADDRESS:7 HERMOSA LANETELEPHONE:
(650) 872-5006
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
11/21/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:13 PM
MET WITH:Josephine ManzanoTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 11/21/24, 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 currently watching tv in the living room. LPA reviewed the emergency drill in-service training, which happened this November 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 received.

No citations issued today.

Report is reviewed with and a copy is provided.
Andrea MedlinTELEPHONE: (650) 266-8811
Grace DonatoTELEPHONE: (714) 293-8294
DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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