415601175-12-16-2024-14-AS-ACON-DCGVG6-20241231152502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601175
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:47:43 PM

Unfounded

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
09/12/2024 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240912145409

FACILITY NAME:	TLC HOME CARE V		FACILITY NUMBER:	415601175
ADMINISTRATOR:	MAURICIO, LILIA L		FACILITY TYPE:	740
ADDRESS:	716 NORTH HUMBOLDT ST		TELEPHONE:	(650) 952-1687
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	6	CENSUS: 5	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Joebelle Payumo and Rose Masagca		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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- Staff did not refund authorized representative after resident's death

INVESTIGATION FINDINGS:

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The complaint alleging that refund was not issued after resident passed away has been investigated by the Community Care Licensing Division of the CA Department of Social Services, and determined to be unfounded. This means that the allegation could not have happened and/or is without a reasonable basis.

Immediately after the death of client on 8/27/24, personal belongings were removed by responsible party and the room was vacated. A refund check was issued on 8/29/24 for 4 days and mailed. However, the address was incorrect, and the envelope was undeliverable; it was returned to licensee on 9/17/24.

On 9/17/24, it was confirmed that appropriate refund was received.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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