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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602193
Report Date: 05/13/2021
Date Signed: 05/20/2021 03:23:30 PM

Document Has Been Signed on 05/20/2021 03:23 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:TERRA VERDE LIVING LLCFACILITY NUMBER:
198602193
ADMINISTRATOR:JASON M. BLACKFACILITY TYPE:
740
ADDRESS:27563 LONGHILL DRIVETELEPHONE:
(310) 525-8552
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
05/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Tina Cinco, LicenseeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required visit to the above facility. LPA was met by Geno Benosa, House Manager and later met with Tina Cinco, Licensee and the purpose of today’s visit was explained.

There are currently (6) residents in the facility. (3) residents are ambulatory and (3) are non-ambulatory. 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 (5) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and a detached garage.

LPA and Geno toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Medications are current. Ample supply of perishable and nonperishable food, hot water temperature is 120 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 2 fire extinguisher are fully charged, fire drill conducted on 04/2021. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. LPA observed staff and clients wearing masks, clients private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The facility has an approved Mitigation plan. The clients temperature's are checked and logged once a day. PPE's are enough for 30 days.

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

An exit interview conducted with Tina Cinco, Licensee and copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2021
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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