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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208261
Report Date: 11/05/2021
Date Signed: 11/05/2021 05:16:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:TLC ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
547208261
ADMINISTRATOR:COSTA, LORETTA M.FACILITY TYPE:
740
ADDRESS:2530 S BEN MADDOX WAYTELEPHONE:
(559) 627-5684
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:26CENSUS: 16DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Administrator Loretta Costa; Assistant Administrator Brian CostaTIME COMPLETED:
05:15 PM
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An Annual Inspection Control visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Administrator (Admin) Loretta Costa & Assistant Administrator (AA) Brian Costa & stated purpose of visit.

One central entry point has been designated for universal entry screening. Routine symptom screening including temperature taken & recorded daily for all staff, residents, & visitors.
Infection Control signs are posted, including in bathrooms with hand washing techniques. Soap & paper towels available. Hand sanitizer available on entry & throughout the facility. Face coverings in use & available. Sufficient supply of PPEs. Infection control policies & procedures & practices in place & currently applied.

No deficiencies issued.
Exit interview conducted with Admin & AA. Report Provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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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