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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601175
Report Date: 03/06/2024
Date Signed: 03/06/2024 09:29:36 AM

Document Has Been Signed on 03/06/2024 09:29 AM - 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 HOME CARE VFACILITY NUMBER:
415601175
ADMINISTRATOR:MAURICIO, LILIA LFACILITY TYPE:
740
ADDRESS:716 NORTH HUMBOLDT STTELEPHONE:
(650) 952-1687
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
03/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Joebelle PayumoTIME COMPLETED:
09:45 AM
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LPA Jeung reviewed modifications made as per pre-licensing visit of 2/16/24. LPA observed the following:

1. Complaint information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints (PUB475), is posted prominently in area accessible to residents, representatives, and the public. (87468 Personal Rights)
2. Admission agreement, modifications and attachments, or notice of their availability, is conspicuously posted in a location accessible to public view in the facility. (87507 Admission Agreements)
3. An internet access device dedicated for resident use--such as a computer, smart phone, tablet, or other device that can support real-time interactive applications, equipped with videoconferencing technology, including microphone and camera functions--is acquired and maintained. (HSC 1569.319)
4. A spare set of keys--including all resident units, facility vehicles, all exit doors, all cabinets, cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies--is available to staff on each shift for use during an emergency evacuation. (1569.695)

Facility meets physical plant requirements for RCFE licensure for 6 non-ambulatory elderly clients over age 59 in 6 rooms. Fire clearance has been approved.

Immediate licensure is recommended, pending final approval from Central Applications Unit.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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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