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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320486
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:45:29 PM

Document Has Been Signed on 01/22/2025 12:45 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:TC CARES IIIFACILITY NUMBER:
198320486
ADMINISTRATOR/
DIRECTOR:		WALLACE, HENRYFACILITY TYPE:
740
ADDRESS:3355 W. 117TH STREETTELEPHONE:
(310) 940-4624
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 0DATE:
01/22/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Henry Wallace TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 01/22/2025, Licensing Program Analyst’s (LPA’s) Yolanda Rosser conducted an Announced Pre-Licensing visit. LPA Rosser met with and toured the facility with Licensee Henry Wallace. The facility plans to support individuals who are 60 years of age and above. The facility has a fire clearance for (6) ambulatory residents.

The facility is a single-story residence to include three bedrooms and one restroom. LPA Rosser observed the following during a tour of the facility Fire Extinguisher was purchased 07/03/2024, living room with new couch and love seat, with space for activities (games and activities were located in a storage area underneath the television, dining room area with space to accommodate four (4) people, kitchen with table and chairs to accommodate three (3) people.

The areas inspected have the required furnishings, lighting, and storage. LPA, observed 3 days of non- perishables and 7 days of perishables. LPA Rosser toured the detached garage used strictly for storage and is non-accessible to residents. The backyard has a block brick wall surrounding it. The backyard has a seating area with chairs and a tent for shade. The front yard landscape is neat and clean. The walkways around the facility are free of obstructions and no debris. The entrance is equipped with a ramp.

LPA Rosser conducted a test of the smoke and carbon monoxide detectors and found them to be functioning properly. continued on LIC 809 C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: TC CARES III
FACILITY NUMBER: 198320486
VISIT DATE: 01/22/2025
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The residence has a washer and dryer unit. There is extra lighting and batteries. The cutlery's were stored and locked. Entrance closet will maintain medication and employee records which has a lock on the door. The residence has extra linen, blankets, pillows and towels. Extra hygiene items were stored in hallway closet.

The bedrooms met Title 22 requirements.

The residence is very neat and clean. All poster and signage were posted.
An exit interview was conducted, and a Facility Evaluation Report and Appeal Rights were provided to Henry Wallace, Administrator..
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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