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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208261
Report Date: 01/29/2024
Date Signed: 01/29/2024 06:59:15 PM


Document Has Been Signed on 01/29/2024 06:59 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
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: 19DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Assistant Administrator (AA) Brian Costa; Registered Nurse (RN) & Assistant to the Administrator Cynthia CostaTIME COMPLETED:
07:15 PM
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An unannounced Annual visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Assistant Administrator (AA) Brian Costa; Registered Nurse (RN) & Assistant to the Administrator Cynthia Costa.

This facility is fire cleared for delayed egress. Hospice waiver granted for sixteen (16).
Physical Plant toured. Kitchen area toured. 2 day supply perishable & 7 day supply non-perishable food observed on the premises. Tight fitting lids on trash cans.
Lobby, front sitting rooms, & dining room sufficiently furnished with sufficient lighting. Furnishing observed to be in good repair & appear to be clean with no unpleasant odors. Resident rooms observed to be sufficiently furnished with adequate lighting. Resident bathrooms appeared to be clean with no unpleasant odors. Grab bars in all toilets, tub, & shower areas. Non-skid mats in tub/showers. Hot water measured at 107 degrees F. Auditory alarms on exits. Outside area toured. No hazards observed. Interior & exterior walkways observed to be clear & free from obstruction.

Medications observed to be stored in locked area. Cleansers, soaps, etc stored in area inaccessible to residents. Smoke & carbon monoxide detectors operational. Fire extinguisher service date: 12/22/2023

Records review to be continued during a later visit.

No deficiencies observed.
Exit interview conduced with AA & RN. Copy of report provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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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