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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320486
Report Date: 02/19/2026
Date Signed: 02/19/2026 10:32:33 PM

Document Has Been Signed on 02/19/2026 10:32 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: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:
02/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Henry WallaceTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Annual Required 1 Year Visit with the primary focus on infection control measures and the use of the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the evaluation, the facility is clear of COVID-19 infection. LPA Bunker met with Licensee/Administrator Henry Wallace and explained the purpose of today's annual inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Report. There are currently no residents in placement, and the facility’s annual fees are up to date.

The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records-Training/Staff Training, Resident Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness, and Resident with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

LPA Bunker and Licensee/Administrator conducted a tour of the facility, which is a single-story family home located in a residential neighborhood. The home includes a living room, dining room, kitchen, three bedrooms, one bathroom, a laundry room, a detached garage, and an indoor/outdoor activity area. Bedrooms #1-3 are designated as the resident's bedrooms. There is a shaded outdoor space furnished with patio furniture, including tables and chairs.

See continued LIC809-C page 2
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2026
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: TC CARES III
FACILITY NUMBER: 198320486
VISIT DATE: 02/19/2026
NARRATIVE
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Continued LIC802-C page 2

LPA Bunker observed the facility’s infection control practices, which included screening protocols for residents and visitors, the availability of hand sanitizer, a visitor log, and the use of thermometers in the facility's living room. Logs documenting daily COVID-19 screenings and temperature checks for both residents and staff were available and up to date. Personal Protective Equipment (PPE) supplies were readily accessible to staff, and an additional supply of PPE was also observed. Additionally, sufficient liquid soap, paper products, cleaning supplies, and disinfectants were available.

Required documents are posted on the bulletin board located on the kitchen wall. The following Title 22-regulated areas were audited and found to be in compliance:

• Telephones: Facility telephones are operational.

• Bedrooms: All bedrooms meet the required standards for furniture, safety, privacy, and comfort. An adequate supply of linens is available.

• Bathroom: The bathroom is clean, fully operational, and equipped with non-skid surface mats to ensure safety and privacy.

• Kitchen and Food Service: Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of food supplies confirmed an ample stock of both perishable and non-perishable items, stored in an appropriate manner.

• Medication Storage and Management: All medications will be securely stored in a locked cabinet located in the entryway closet. Documentation will remain current to ensure accurate records and full compliance with storage requirements.

• Common Areas: The living room, dining room, and other shared spaces are well-maintained, free of hazards, and meet cleanliness standards essential for resident safety and well-being.

See continued LIC812-C page 3.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: TC CARES III
FACILITY NUMBER: 198320486
VISIT DATE: 02/19/2026
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Continued LIC812-C page 3.

• Safety Equipment and Measures: The facility is equipped with a fully stocked first aid kit and manual, functional smoke and carbon monoxide detectors, and properly charged fire extinguishers. Hot water temperature was measured at 120°F, within the acceptable range of 105–120°F.

• Emergency Preparedness: All exit doors are in compliance. Bedroom windows are fitted with sliding locks that do not use thumbscrews.

• Environmental Safety: The yard is free of debris and hazards. Trash cans are covered, and there are no firearms or bodies of water on the premises. Hazardous items are stored securely and remain inaccessible to clients.

• Staff Training: Staff have received training on dependent adult and elder abuse reporting.

• Administrative Compliance: The Administrator’s Certificate is current. HIV/TB compliance requirements have been verified.

LPA Bunker provided Licensee/Administrator Henry Wallace with a copy of the facility evaluation report, LIC809, and LIC809-C.

No deficiencies were cited.

An exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4