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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601175
Report Date: 12/16/2024
Date Signed: 12/16/2024 06:02:09 PM

Document Has Been Signed on 12/16/2024 06:02 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: 5DATE:
12/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Joebelle Payumo and Rose MasagcaTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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During complaint investigation, deficiencies of the California Code of Regulations, Title 22 were observed and are cited on a following page.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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Document Has Been Signed on 12/16/2024 06:02 PM - It Cannot Be Edited


Created By: Audrey Jeung On 12/13/2024 at 05:57 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: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2024
Section Cited
CCR
87615(a)(1)

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PROHIBITED HEALTH CONDITIONS
Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a RCFE:
Stage 3 and 4 pressure injuries.
This requirement was not met, as former
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Plan of correction to be submitted to CCLD BY DUE DATE, describing how this situation will not recur
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client was assessed to have stage III pressure injury on 3/27/24, which was being treated by home health. Licensee failed to relocate client to higher level of care or request exception from CCLD, which posed an immediate health, safety or personal rights 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.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2024 06:02 PM - It Cannot Be Edited


Created By: Audrey Jeung On 12/13/2024 at 06:07 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: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited
CCR
87609(b)(3)

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ALLOWABLE HEALTH CONDITIONS & USE OF HOME HEALTH AGENCIES
Incidental medical care may be provided to residents through a licensed HH agency provided...the licensee informs the HH agency of any duties the regulations prohibit facility staff from performing, and of any
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Licensee to submit plan to CCLD BY DUE DATE for ensuring that HH agencies are informed about limitations of facility staff duties and regulations pertaining to clients' specific health conditions.
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regulations that address the resident’s specific condition(s). This requirement was not met, as staff did not inform HH that they were not qualified to perform wound care nor that stage III pressure ulcers were prohibited, which posed a potential health, safety, or personal rights risk to clients in care.
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Type B
12/27/2024
Section Cited
CCR87609(b)(4)(B)

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ALLOWABLE HEALTH CONDITIONS & USE OF HOME HEALTH AGENCIES
The licensee & HH agency agree in writing on the responsibilities of the HH agency, & ...of the licensee in caring for the resident’s medical condition(s)... shall include day & evening contact information for the
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Licensee to submit plan to CCLD BY DUE DATE for ensuring that HH notes are maintained whenever clients receive HH nursing care
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HH agency, & the method of communication between the agency & the facility, which may include ... logbook. This requirement was not met, as facility failed to maintain written record from HH of client's condition, which posed a potential health, safety or personal rights 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.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
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