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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600928
Report Date: 07/06/2023
Date Signed: 07/07/2023 08:59:38 AM

Document Has Been Signed on 07/07/2023 08:59 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:
07/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Josephine ManzanoTIME COMPLETED:
10:30 AM
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On 7/6/2023, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning a staff member not associated in the facility. LPA met with caregiver Josephine Manzano. LPA explained the purpose of today's visit.

On 6/23/22023, LPA visited the facility for an annual and was able to confirm that one staff member is not associated with the facility. Licensee was given time to associate the staff member but couldn’t do so. The facility was able to provide proof that they have submitted the requirements, through fax, to CCLD office on 6/8/2023.

No deficiency cited today. Report is reviewed and and copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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