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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600928
Report Date: 06/23/2023
Date Signed: 06/26/2023 09:47:39 AM

Document Has Been Signed on 06/26/2023 09:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:TLC HOME CAREFACILITY NUMBER:
415600928
ADMINISTRATOR:MAURICIO, LILIA L.FACILITY TYPE:
740
ADDRESS:7 HERMOSA LANETELEPHONE:
(650) 872-5006
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 4DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Josephine ManzanoTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Grace Donato made an unannounced annual visit to the facility. LPA met with caregiver Josephine Manzano. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including resident rooms, common areas, garage & bathrooms. The indoor and outdoor passageways were free of obstruction. The residents have adequate amount of linens in their bedrooms. All personal belongings are intact. While touring the facility it was observed that the room temperature was at 75 deg F. Resident bedrooms and bathrooms were observed to be in good repair. Bathrooms are equipped with grab bars and non-skid floors and mats. Carbon monoxide monitor are working properly. All fire extinguishers have been checked and current. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Sharps and chemicals are locked and inaccessible to residents. Emergency drill has only been done once a year.

Hot water was also tested in the bathrooms and the temperature was 140 deg F. It was corrected by facility staff right away. Temperature went down to 120 deg F.

Per facility sketch, Room No. 5 was used as a staff room instead of a resident room.

It was observed that there is a double decker bed at the garage. Facility staff is going to remove and dispose of it by 06/30/2023.

Two resident records and four staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirements. 1 out of 4 staff member is currently taking trainings that are required. Facility has a certified administrator with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TLC HOME CARE
FACILITY NUMBER: 415600928
VISIT DATE: 06/23/2023
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Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA interviewed 2 residents and 2 staff members.

LPA requested to submit the following and was received in the facility at 6/23/2023:

LIC 308 Designation of Facility Responsibility
Administrator Certificate
LIC 500 Personnel Report
Liability Insurance

To be emailed to LPA or faxed by 6/30/2023:
Control of Property

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. A technical violation was given. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/26/2023 09:47 AM - It Cannot Be Edited


Created By: Grace Donato On 06/23/2023 at 01:46 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TLC HOME CARE

FACILITY NUMBER: 415600928

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above due to emergency drills has only been done once a year, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee shall ensure to provide written proof of in service log for emergency drill and that the drill will be held quartelry after that.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

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 due to per facility sketch, Room No. 5 was used as a staff room instead of a resident room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee shall ensure that the facility sketch is updated POC due date.
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:Jackie Jin
LICENSING EVALUATOR NAME:Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
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