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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601139
Report Date: 12/19/2024
Date Signed: 12/19/2024 04:00:15 PM

Document Has Been Signed on 12/19/2024 04:00 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 PACIFICAFACILITY NUMBER:
415601139
ADMINISTRATOR/
DIRECTOR:
TOPIRCEANU, CRISTIANFACILITY TYPE:
740
ADDRESS:689 LADERA WAYTELEPHONE:
(714) 916-7342
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 16CENSUS: 14DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Camille Mcfarlane, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 12/19/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver, Camille McFarlane. Licensee Christian Topirceanu was notified but unable to attend the visit. The facility currently provides care for 14 residents, one of which are currently receiving hospice services and some of which with a diagnosis of dementia.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located throughout the hallways, kitchen and common spaces were found to be charged. Facility is equipped with interconnected smoke and carbon monoxide detectors all of which were found to be in working order.

There was a sufficient supply of both perishable and nonperishable foods as required, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished weekly and stored in proper conditions. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed if any. Cleaning supplies and other toxins are safely stored in locked in designated storage cabinets and laundry room, which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items.

Residents that were out in the community were observed interacting with staff, fellow residents in the common areas, participating in activities and family visits. The facility encourages regular family visits and utilizes a large backyard patio, deck space and common areas. Residents that were interviewed during the inspection indicated exceptional care services from staff and reported no concerns.

Continued onto LIC809-C
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TLC PACIFICA
FACILITY NUMBER: 415601139
VISIT DATE: 12/19/2024
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LPA conducted a sample file review for residents and found that the reappraisals were all up to date. LPA however found that the facility is in the process of updating medical assessments for residents with a diagnosis of dementia. LPA determined that the facility has taken appropriate steps and actively working on completing medical assessments. Technical Violation issued. Upon a sample file review for staff, LPA found that annual training requirements and 1st aid & cpr certification were completed.

LPA requested the following documents be sent to CCL by COB 1/9/2025:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan

No deficiencies cited during today's visit.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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