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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209106
Report Date: 01/28/2025
Date Signed: 01/28/2025 09:22:53 PM

Document Has Been Signed on 01/28/2025 09:22 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 HOME CARE 1FACILITY NUMBER:
157209106
ADMINISTRATOR/
DIRECTOR:		ARRIETA, RODRIGO A. JR.FACILITY TYPE:
740
ADDRESS:5801 COCHRAN DRIVETELEPHONE:
(661) 558-4499
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 5DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Teresa Reyes, Care StaffTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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LPA Katie Brown arrived at the facility unannounced to conduct the Annual Inspection, Upon arrival, LPA was informed by Staff (S1) Teresa Reyes that Administrator (AD) was available by phone. AD, Rodrigo Arrieta was contacted. LPA spoke to AD on the phone who authorized S1 to meet with LPA and sign the reports. AD was available during the visit for questions.

During this visit, LPA toured the facility inside & out. Resident rooms and common areas were clean, in good repair and contained required equipment, furnishings and lighting. LPA observed required items in bathrooms which were clean. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were stored and available for use. The kitchen was found to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals were locked are stored separate from food. Medications are centrally stored in a locked kitchen cabinet. Overflow medications and medication refrigerator are kept in a locked area. First Aid kit contained required items. Fire extinguishers were found to be charged and were serviced 9/17/24 by Independent Fire & Safety Co. Smoke detectors were observed and tested.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Fire Clearance and Incidental Medical & Dental Care Services.



An Immediate $500 Civil penalty is being assessed on the attached LIC421IM

An exit interview was conducted and Plan of Correction (POC) developed with AD via phone call. A signed copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 01/28/2025 09:22 PM - It Cannot Be Edited


Created By: Katie Brown On 01/28/2025 at 02:36 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 1
FACILITY NUMBER: 157209106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed S1 administer an Insulin Injection for R3.
POC Due Date: 01/29/2025
Plan of Correction
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Licensee has agreed to immediately assign a facility LVN to assist R3 with Insulin injections until updated physician orders and Physicians report to obtained. A writen statement will be faxed to CCL which explains the plan to meet the needs of R3 relating to Insulina dn Diabetes management. The statement will be faxed by poc date
Type A
Section Cited
CCR
87758(a)
87758 Serious Deficiencies – Examples (a) Regulations including but not limited to the following may result in serious deficiencies when a failure to comply presents an immediate or substantial threat to the physical health, mental health, or safety of the residents: (2) Section 87202 relating to fire clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and intervie, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Licensee has altered the facility building by adding exit doors to each resident room without proper fire clearance or pcity permits. Two of the newly added doors are completely blocked by resident beds and a third is obstructed by forniture and resident bed. The fire marshall or licensing were not informed.
POC Due Date: 01/29/2025
Plan of Correction
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Licensee has agreed to rearrange the 3 resident rooms to comply with fire clearance access to exits. The fire Marshall will be contacted and notified of the facility alterations and CCL will be notified in writing of the plan moving forward to obtain proper clearance.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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