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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600928
Report Date: 09/01/2023
Date Signed: 09/02/2023 12:44:33 AM

Document Has Been Signed on 09/02/2023 12:44 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:
09/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:18 PM
MET WITH:Josephine Manzano & Emerita MallariTIME COMPLETED:
04:00 PM
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On 9/1/2023, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning a request from licensing about the Control of Property. LPA met with caregivers Josephine Manzano & Emerita Mallari. LPA explained the purpose of today's visit.

On 8/24/23, Facility submitted and Amendment to Lease document. CCLD wasn't able to receive it through fax when it was sent. LPA obtained the copy today, 9/1/23. The original request was for the Commercial Lease Agreement be sent. LPA called the administrator to explain what is required by Licensing per regulation. Administrator stated that she will call the property owners again to request a new agreement. LPA gave the Administrator a deadline of 9/8/23 to provide a copy to LPA.

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: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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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