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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208261
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:32:25 AM


Document Has Been Signed on 01/26/2023 11:32 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
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: 15DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Register Nurse Cynthia Costa, Administrator Loretta Costa, and Assistant Administrator Brian Costa TIME COMPLETED:
11:45 AM
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On 1/26/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA was greeted with Kassandra Rodriguez and granted entry into faciltiy. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Register Nurse (RN) Cynthia Costa. Administrator Loretta Costa was called and unable to attend meeting. Administrator authorized RN to receive and signed report. All 15 residents were present during the inspection. Administrator Loretta Costa and Assistant Administrator Brian Costa arrived shortly.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed in the facility.

Cleaning supplies were stored and locked in cleaning closet. LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. 30 days PPE supplies was observed. All resident’s room toured and observed to be adequately furnished and lit. All shared bedroom LPA observed residents’ bed to be at least 6 feet apart. All bathrooms are observed with securely fastened grab bars. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks.

Staff records were reviewed for good health and infection control training. Half of the resident’s records were reviewed and have updated emergency contact information. Staff records were reviewed for good health and infection control training.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 3/7/22. The following updated forms were requested: Lic 309, Lic 500, and Lic 610E. LPA received a copy of the Lic 9282, Lic 308, current liability insurance and current Administrator certificate. A copy of this report was provided to Administrator, RN and Assistant Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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