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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850566
Report Date: 03/14/2025
Date Signed: 03/14/2025 04:15:58 PM

Document Has Been Signed on 03/14/2025 04:15 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TLC SENIOR CAREFACILITY NUMBER:
405850566
ADMINISTRATOR/
DIRECTOR:
RICCI, DAVINAFACILITY TYPE:
740
ADDRESS:1007 NICE AVETELEPHONE:
(916) 284-1227
CITY:GROVER BEACHSTATE: CAZIP CODE:
93433
CAPACITY: 6CENSUS: 0DATE:
03/14/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Davina Ricci, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) De Leon conducted a pre-licensing visit to the facility above. LPA met with Davina Ricci, Administrator and explained the purpose of the visit.

LPA toured the inside and outside of the facility.

The facility has a plan of operation, Emergency Disaster plan, and Infection control plan on file.

The facility is a 4 bedroom and 2 bathroom home with a living room, dining room, and kitchen.
The facility has a front yard, back patio and side patio with furniture and shade for resident use.
The facility has emergency supplies, food, water and personal protective equipment for resident, visitor and staff use.

The facility has a common area hallway with all postings of personal rights, Rights to residents councsel , non-discrimination notice, emergency and infection control plans, and CCL Complaint poster. The Administrator will contact LTCO to obtain their poster.

The facility is set up for dementia residents.
Sharps and knives will be stored in a locked drawer in the kitchen.
Staff and resident files will be kept confidential in file cabinet.
The facility has alarms on all exiting doors.

Yards have locked storage sheds with gardening tools and a locked storage shed with additional supplies.
Gates will be fixed to self close and latch and the living room area has a fire place that needs to have a secured cover in place. Administrator will send LPA a picture once fixed.

Exit interview completed, copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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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