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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601139
Report Date: 02/01/2023
Date Signed: 02/01/2023 02:06:55 PM

Document Has Been Signed on 02/01/2023 02:06 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 PACIFICAFACILITY NUMBER:
415601139
ADMINISTRATOR:TOPIRCEANU, CRISTIANFACILITY TYPE:
740
ADDRESS:689 LADERA WAYTELEPHONE:
(714) 916-7342
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 16CENSUS: 11DATE:
02/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Cristian L TopirceanuTIME COMPLETED:
02:20 PM
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On 2/1/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Pre-Licensing visit. LPA met with Administrator, Cristian Topirceanu and explained the purpose of the visit. Upon arrival, LPA observed the COVID-19 signage posted on the front entrance and screening station.

LPA toured the facility and grounds. Indoor and outdoor passageways and stairways are free of obstruction. No accessible bodies of water or fire safety hazards observed. This is a two story facility with 11 bedrooms (4 bedrooms on the lower level and 7 bedrooms on the upper level), and 5 bath/shower rooms. LPA toured the facility with the Administrator and observed the bedrooms are spacious, bright and cleaned. The beds in the share bedrooms are 6ft apart. All bedrooms contained the required furniture and lighting requirements per CCLD regulations. LPA observed the 30-day PPE supply to be adequate. Locked medication cabinet is observed to be located in the kitchen.

LPA inspected the kitchen and dining room area. Trash cans are observed to have foot operated lids. Dining room area is observed to be clean and in order. Chairs are in place. Both fresh food and frozen food supplies are inspected and observed to be sufficient, Dry goods/emergency food supplies are present. Freezer temperature observed at 0 degrees F and refrigerator temperature observed at 41 degrees F. Toxins, chemicals, and sharps were locked and stored appropriately and inaccessible to residents. All required facility postings are posted by the facility entrance.

Bathrooms were observed to be equipped with paper towels, hand-washing signs, liquid soap, trash cans with fitted lids, and non-skid mats. Shower rooms are observed to have grab bars and non- skid mats and shower chairs. Water temperature throughout the facility was measured between 105- 114 degrees F. Facility was maintained at a comfortable temperature- 71-73 degrees F. Smoke detectors, fire alarms, and carbon monoxide systems are operating properly. COVID-19 signs are posted throughout the facility. First aid kit was observed to be located in the kitchen cabinet and complete. Extra linen was present. LPA observed the outdoor patio to be clean and clear.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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 2
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 PACIFICA
FACILITY NUMBER: 415601139
VISIT DATE: 02/01/2023
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Facility is clean and in good repair during today's inspection. . Facility is in compliance with Title 22 regulations. No citations are issued. Immediate licensure is recommended, pending final approval by Centralized Applications Unit.

Component III is conducted.

This report is reviewed with Administrator. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC809 (FAS) - (06/04)
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