<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602193
Report Date: 05/10/2024
Date Signed: 05/10/2024 02:17:03 PM

Document Has Been Signed on 05/10/2024 02:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:TERRA VERDE LIVING LLCFACILITY NUMBER:
198602193
ADMINISTRATOR/
DIRECTOR:		LAYUG, TINYFACILITY TYPE:
740
ADDRESS:27563 LONGHILL DRIVETELEPHONE:
(310) 525-8552
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Jeno Benosa/House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:16 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/10/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Jeno Benosa /House Manager. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) elderly adults ages 60 and above of which (6) can be non-ambulatory, of which (1) may be bedridden in bedroom #1 or #2. Facility has an approved hospice waiver for (3).

The facility is a single-story structure located in a residential neighborhood. It has a ramp that goes along the west side of the facility. It consists of (6) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and attached garage.

LPA Iniguez toured the physical plant with Administrator. There were no bodies of water or obstructions on the premises. A total of (6) bedrooms and (2) bathrooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide are all operable conditions. The water temperature ranged from 108.5F° – 115.2F°. The room temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: TERRA VERDE LIVING LLC
FACILITY NUMBER: 198602193
VISIT DATE: 05/10/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Cleaning supplies, toxins, and sharps objects were stored and not accessible to residents in care. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 4/5/24.

A review of (3) residents' service files and (3) staff personnel files were maintained in order. LPA reviewed (3) Medication Administration Records (MARs) no discrepancies were found.

LPA observed the facility's infection control practices. All mandated inspection control posters were posted throughout the facility. Copy of liability insurance was provided to LPA during the visit. Facility Annual Fess current.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Jeno Benosa /House Manager.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2