<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208261
Report Date: 12/23/2024
Date Signed: 12/23/2024 12:57:38 PM

Document Has Been Signed on 12/23/2024 12:57 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:TLC ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
547208261
ADMINISTRATOR/
DIRECTOR:
COSTA, LORETTA M.FACILITY TYPE:
740
ADDRESS:2530 S BEN MADDOX WAYTELEPHONE:
(559) 627-5684
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 26TOTAL ENROLLED CHILDREN: 0CENSUS: 21DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:59 AM
MET WITH:Administrator: Cynthia CostaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/23/2024, Licensing Program Analyst LPA J. Leffall arrived at the facility unannounced to conduct the Required Annual Inspection. LPA was greeted by Resident Assistant (RA) Jayden Costa. LPA stated the purpose of the visit. Administrator (A1) Brian Costa arrived shortly after LPA’s arrival. LPA conducted tour of facility with A1. Residents were observed in open living area.

The facility was observed to be at a comfortable temperature, clean, in good repair with no passageway
obstructions or fire hazards. Fire extinguisher was observed with a service date of: 12/17/2024. Kitchen was
toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in
freezer and refrigerator. Refrigerator temperature was observed maintained at 35 degrees F. and freezer was
observed maintained at 2 degrees F. All chemicals were in locked storage area. LPA toured samples of resident’s bedrooms, dining room and enclosed patio area. Residents' rooms were toured and observed with adequately furnished bed, dresser, and adequate lighting. LPAs observed grab bars next to toilet and all tub/shower areas. 5 out of 5 residents rooms observed with non-skid shower strips. 5 out of 5 residents bathroom temperatures measured at 105, 112.8, 116.4, 112.4, and 105, degrees F.

LPA completed a medication audit. Medications were stored in a locked medication room in a medication cabinet. MARs and medications were reviewed. LPA observed secured Centrally Stored Medication Record. Samples of staff files were reviewed to have all of the required documents. Samples of resident’s files were reviewed to have all the required documents.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 1/6/25: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report.

See MouaTELEPHONE: (559) 580-4596
Jacques LeffallTELEPHONE: 559-243-8080
DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1