198602983-11-22-2023-11-AS-RCLD-CXTTF2-20231122134050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602983
Report Date: 11/22/2023
Date Signed: 11/22/2023 01:41:01 PM

Document Has Been Signed on 11/22/2023 01:41 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	TARRASA		FACILITY NUMBER:	198602983
ADMINISTRATOR:	MATT PALMER		FACILITY TYPE:	740
ADDRESS:	27612 TARRASA DR		TELEPHONE:	(424) 267-6267
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 6	DATE:	11/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Liza Sergio		TIME COMPLETED:	01:50 PM

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On 11/22/23 at 10:18 am Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced visit to this facility. The purpose of today’s visit was to conduct an annual inspection. LPA met with House Manager Liza Sergio. The facility is licensed for (6) non-ambulatory of which (1) maybe bedridden ages 60 and above. The facility is licensed for (6) hospice. Currently, there are (3) residents on hospice. Liza Sergio contacted Licensee Matthew Palmer by phone to inform him of our visit.

LPA toured the physical plant and inspected food service, reviewed (5) staff records, and reviewed (5) resident files for medical status. LPA observed (2) Medication Administration Records (MAR) that were maintained in order. All records are upheld and in compliance. The last fire a drill was conducted 11/03/2023. The facilities consist of (5) resident bedrooms and (2) resident bathroom. There’s (1) bedroom for live-in staff and (1) staff bathroom. The facility has living room, dining room, and kitchen and activity room. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms are clean, sanitary and fixtures are working properly. Bathrooms grab bars are secure and non-skid mats in place. The facility water was tested by LPA which measured at 108.5 degrees F. Resident's bath towels, toiletries, and personal hygiene supplies were adequately stocked. Common areas were free from obstruction. All doors and windows have alarms. Fire extinguishers (2) are fully charged in kitchen and in garage last inspected 10/04/2023.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. The medications were securely locked and inaccessible to residents in hall cabinet.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TARRASA	FACILITY NUMBER: 198602983
	VISIT DATE: 11/22/2023

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LPA tested smoke detectors and carbon monoxide detectors and found to be operating properly. The First Aid kit is fully stocked. Outside grounds were toured and no bodies of water were observed around the home were clear of hazards. There are no security bars or weapons on the premises.

Administrator’s Certificate Program are current. Two (2) staff and (2) clients were interviewed. All required mandated posters are posted in dining room area.

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

Exit interview conducted and a copy of report was provided to the House Manager Liza Sergio with signature confirming receipt of report.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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