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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603383
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:19:41 PM


Document Has Been Signed on 05/04/2022 04:19 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THEFACILITY NUMBER:
198603383
ADMINISTRATOR:HIGGINS, DEBORAHFACILITY TYPE:
740
ADDRESS:1155 VIA VERDETELEPHONE:
(503) 443-1818
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:60CENSUS: 25DATE:
05/04/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator Vicky TorresTIME COMPLETED:
11:45 AM
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
Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced case management visit in order to conduct a health and safety check due to incident report received on 4/18/22. LPA met with administrator Vicky Torres and the purpose of the visit was discussed.

On todays visit LPA conducted a health and safety check. LPA toured the physical plant of the facility and did not observe any path obstructions or health and safety hazards. LPA observed the food supply and toxins and sharps were locked and inaccessible to residents in care. LPA obtained a copy of the Staff and Resident roster during the visit.

No deficiencies cited on todays visit and a copy of this report was provided to Vicky Torres
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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 1