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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209106
Report Date: 10/15/2025
Date Signed: 10/15/2025 12:52:46 PM

Document Has Been Signed on 10/15/2025 12:52 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 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: 6DATE:
10/15/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Rodrigo Arrieta Jr.TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 10/15/2025, Licensing Program Analysts (LPAs) M. Medina and J. Duarte conducted a Case Management visit to document observations made during complaint visit. LPAs arrived, introduced themselves and allowed entrance by direct care staff. Licensee/Administrator, Rodrigo Arrieta contacted by telephone and arrived a short time later to conduct visit with LPAs

During complaint visit, it was observed that Staff 1 (S1) has been working daily since 10/10/2025, fingerprint cleared but not associated to facility.

LPA's observed that the front door auditory alarm was in place but not in the "on" position upon arrival. Four of four exit doors from resident bedrooms did not have auditory alarms, and the sliding door to back yard had an auditory alarm that was not "on" during inspection.

LPA's observed a small clear bin in the kitchen with several medication bottles belonging to staff 2 (S2) in the kitchen area unsecured and accessible to residents. LPAs also observed a family member of R1 arrive and remove medication from refrigerator to administer an injection, medication was not locked and secured. LPAs also observed the cabinet beneath kitchen sink to be unlocked and accessible to residents, which contains cleaning supplies.

Based on today's case management visit, and per CCR Title 22, deficiencies are being cited on the attached 809-D. Immediate civil penalties are being assessed in the amount of $500 for Caregiver transfer request, and $500 for fire clearance totalling $1000. If not corrected, the violations will have a direct and immediate risk to the health, safety, or personal rights of clients in care.

Exit interview conducted. A copy of this report and appeal rights provided to Administrator during visit.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Melinda Medina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 10/15/2025 12:52 PM - It Cannot Be Edited


Created By: Melinda Medina On 10/15/2025 at 11:17 AM
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: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2025
Section Cited
CCR
87202(a)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing
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Licensee to change locks to open from interior of bedrooms. Licensee to submit plan of correction to department by due date.


IMMEDIATE CIVIL PENALTY ASSESSED
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agency and obtain an appropriate fire clearance approved by the city, county, or city and count fire department, or district providing the fire protection services, or the State Fire Marshal. ***This was not met as evidenced by 3 of the 4 designated exits from resident rooms were locked requiring key to exit.
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Type A
10/16/2025
Section Cited
CCR87355(e)(3)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility(3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
:
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Licensee to submit LIC 9182 to department and associate S1 to facility and submit plan of correction to department by due date.


IMMEDIATE CIVIL PENALTY ASSESSED
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**This was not met as evidenced by Staff 1 (S1) is fingerprint cleared and not associated to facility. S1 has worked daily since 10/10/25 for a total of 5 days.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Melinda Medina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/15/2025 12:52 PM - It Cannot Be Edited


Created By: Melinda Medina On 10/15/2025 at 11:53 AM
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: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2025
Section Cited
CCR
87309(a)

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(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked
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S2 secured medication in locked staff room and R1's family removed medication to keep at home during visit. Staff also locked cabinet under sink.

DEFICIENCY CLEARED AT TIME OF VISIT.
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storage. ***This was not met as evidenced by LPAs observed a clear bin with S2's medication in the kitchen unsecured. Medication for R1 in the refrigerator unsecured and cabinet under kitchen sink with cleaning supplies unlocked. All accessible to residents.
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,
Type A
10/16/2025
Section Cited
CCR87705(d)

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(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. ***This was not met as evidenced by:
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Licensee/Administrator to add auditory alarms to all exit doors and keep them on. All auditory alarms must remain "on" at all times.
Plan of correction to be submitted to Fresno Regional office by due date.
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LPA's observed that the front door auditory alarm was in place but not in the "on" position upon arrival. Four of four exit doors from resident bedrooms did not have auditory alarms, and the sliding door to back yard had an auditory alarm that was not "on" during inspection.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Melinda Medina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


LIC809 (FAS) - (06/04)
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