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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601175
Report Date: 03/24/2026
Date Signed: 03/24/2026 06:01:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/24/2026 06:01 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 CARE VFACILITY NUMBER:
415601175
ADMINISTRATOR/
DIRECTOR:		MAURICIO, LILIA LFACILITY TYPE:
740
ADDRESS:716 NORTH HUMBOLDT STTELEPHONE:
(650) 952-1687
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
03/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Joebelle PayumoTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, including detached storage building. There are 6 private bedrooms--all with private half or full bathrooms and all with direct exits to outside--staff room, shower room, living room, dining room, and kitchen. There are 2 beds in staff room for 3 staff. Clothes washer and dryer are located in one car garage. The backyard is level, fenced and mostly paved. Medications and toxins are secured in locked cabinets in kitchen and hallway, respectively. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Hot water temperature is tested at 118 degrees in client bathroom #4. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Perishable and non-perishable fruits, vegetables and protein are maintained, as well as supplies of bed and bath linens and hygiene products. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Client files are reviewed, including Centrally Stored Medications Records.
Joebelle Paymuo and Lilia Mauricio are certified RCFE administrators (x 1/28 & 4/26) that oversee facility operations.

The following licensing forms are requested to be completed and submitted to CCLD BY 4/7/26:
- Designation of Facility Responsibility (LIC308)
- Personnel Report (LIC500)

Proof of current liability insurance is given to LPA today.

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Technical Advisory Note--1 page
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/24/2026 06:01 PM - It Cannot Be Edited


Created By: Audrey Jeung On 03/24/2026 at 05:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TLC HOME CARE V
FACILITY NUMBER: 415601175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2026
Section Cited
CCR
87309(a)

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STORAGE SPACE & ACCESS
...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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Detached storage shed will be locked and proof of correction to be sent to CCLD BY DUE DATE
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This requirement is not met. as paint is stored in unlocked storage shed in backyard. Licensee failed to ensure that toxics are inaccessible to clients, which poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2026 06:01 PM - It Cannot Be Edited


Created By: Audrey Jeung On 03/24/2026 at 05:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TLC HOME CARE V
FACILITY NUMBER: 415601175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2026
Section Cited
CCR
87465(h)(6)

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INCIDENTAL MEDICAL CARE
A record of centrally stored Rx medications for each resident shall be maintained and include... pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions. This requirement is not met, as
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CSMRs for ALL residents shall be maintained accurately and reflect information on Rx labels
Proof of correction will be sent to CCLD BY DUE DATE
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Centrally Stored Medication Records reflect incorrect dates filled, expiration dates, quantities, Rx numbers, and some meds are not recorded on CSMR. Licensee failed to maintain accurate CSMRs, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
04/07/2026
Section Cited
CCR87468(b)(1)(A)

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PERSONAL RIGHTS
The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.
This requirement is not met, as Personal Rights forms are incomplete or missing for
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Completed and signed Personal Rights forms for clients #3, #4, #5 will be sent to CCLD BY DUE DATE
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3 out of 6 clients. Licensee failed to ensure that complete Personal Rights forms are maintained for all clients, which poses a potential health, safety or personal rights risk. Clients #3 and #4, have incomplete Personal Rights forms, and there is no Personal Rights form for client #5.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2026 06:01 PM - It Cannot Be Edited


Created By: Audrey Jeung On 03/24/2026 at 05:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TLC HOME CARE V
FACILITY NUMBER: 415601175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2026
Section Cited
HSC
1569.69

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HEALTH AND SAFETY CODE
... the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, & 4 hrs of other training or instruction, as described in
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Staff #2 shall receive required 10 hours of medications , and proof of correction to be sent to CCLD BY DUE DATE
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 subdivision (f), which shall be completed within the first two weeks of employment.
This requirement is not met, as staff #2 has not received required 10 hours of medications training, which poses a potential health, safety or presonal rights risk.
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Type B
04/07/2026
Section Cited
HSC1569.69(b)

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HEALTH AND SAFETY CODE
Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete 8 hours of in-service training on medication-related issues each...12
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Staff #3 will receive additional 4 hours of medications training and proof of correction to be sent to CCLD BY DUE DATE.
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month period. This requirement is not met, as staff #3 has received only 4 hours of annual medication training. Licensee failed to ensure that staff receive required 8 hours of annual medication training, which poses a potential health, safety or personal rights risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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