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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600928
Report Date: 12/17/2025
Date Signed: 12/17/2025 11:28:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2025 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20251112101102
FACILITY NAME:TLC HOME CAREFACILITY NUMBER:
415600928
ADMINISTRATOR:LILIA MAURICIOFACILITY TYPE:
740
ADDRESS:7 HERMOSA LANETELEPHONE:
(650) 872-5006
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 5DATE:
12/17/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Facility Manager, Lourdes Mauricio TIME COMPLETED:
11:37 AM
ALLEGATION(S):
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Staff are falsifying documents
INVESTIGATION FINDINGS:
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On December 17, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Facility Manager, Lourdes Mauricio and explained the purpose of the visit.

Regarding the allegation, staff are falsifying documents, according to the reporting party, on October 20, 2025, staff used Staff 1's (S1's) initials to sign the Medication Administration Record (MAR) even though S1 was not working that day. According to the reporting party, he/she stated that facility staff are not giving the medication to the residents.

During the investigation, LPA reviewed facility's MAR, interviewed staff, and reviewed staff schedule. Staff schedule reviewed showed that S1 was not working on 10/20/25, however based on facility's MAR reviewed, S1's initials were observed on the MAR on 10/20/25 indicating that S1 provided medication to Resident 1 (R1). According to staff interviewed, they were unsure why R1's MAR had S1's initials on 10/20/25.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Facility Manager, Lourdes Mauricio and a copy is provided with appeal rights.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20251112101102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TLC HOME CARE
FACILITY NUMBER: 415600928
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2025
Section Cited
CCR
87207
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87207 False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This regulation is not met as evidenced by:
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Licensee/administrator shall submit a plan in writing describing how licensee will ensure that staff are at all times disseminating truthful statements regarding the facility and operations.
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Based on records reviewed, S1 was not working on 10/20/25, however LPA observed S1's initials signed on R1's MAR on 10/20/25. According to staff interviewed, they are unsure why R1's MAR had S1's initials for 10/20/25.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
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