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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602193
Report Date: 07/18/2025
Date Signed: 07/18/2025 04:16:33 PM

Document Has Been Signed on 07/18/2025 04:16 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:TERRA VERDE LIVING LLCFACILITY NUMBER:
198602193
ADMINISTRATOR/
DIRECTOR:		LAYUG, TINYFACILITY TYPE:
740
ADDRESS:27563 LONGHILL DRIVETELEPHONE:
3105258552
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
07/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Jeno Benosa - House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:26 PM
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On 07/18/25, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced, annual, required visit using the CARE Inspection Tool. LPA was met by staff two, Jeno Benosa - House Manager (S2) and LPA explained the purpose of today’s visit. LPA was later met by staff one, Tina Cinco - Licensee (S1) and staff three, Tiny Layug - Administrator (S3). The facility is licensed to serve (6) elderly adults ages 60 and above of which (6) can be non-ambulatory, of which (1) may be bedridden in bedroom #1 or #2. Facility has an approved hospice waiver for three (3).
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 of six (6) bedrooms (four (4) for resident use, two (2) for staff use), two (2) bathrooms, shaded back yard with seating, shaded front yard with seating, Kitchen, living room, family room ("Sun room"), laundry room and a two-car (2) detached garage.
LPA and S1 toured the physical plant. There were no bodies of water or obstructions on the premises. LPA observed two (2) window screens in disrepair, please see LIC809-D. A total of four (4) resident bedrooms and (2) bathrooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. The facility presents a comfortable indoor temperature at 73.4゜F (degrees Fahrenheit) and hosts two (2) fire extinguishers, which showed the last annual maintenance having been performed on 10/08/24. Smoke and carbon monoxide detectors are all in operable condition. LPA observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Cleaning supplies, toxins, and sharps objects were observed under the sink, unlocked, in bathroom one (#1). Please see LIC809-D. The kitchen was inspected and there is, at least, two (2) days of perishable and seven (7) days of non-perishable food is available and has been maintained properly. Report continues, please see LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
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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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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Document Has Been Signed on 07/18/2025 04:16 PM - It Cannot Be Edited


Created By: Mario Leon On 07/18/2025 at 03:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TERRA VERDE LIVING LLC
FACILITY NUMBER: 198602193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in two (2) out of twelve (12) screens in disrepair and/or missing which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2025
Plan of Correction
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LPA and Licensee have agreed that the two (2) screens, one (1) on the southern wall (SUNROOM WINDOW NEAREST SLIDING DOOR) and one (1) on the western wall (ROOM #4 SCREEN MISSING) will be repaired on or before the POC due date. Licensee will sent photographic evidence via email to LPA at MARIO.LEON@DSS.CA.GOV
Type B
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in one (1) out of two (2) bathroom sink cabinets which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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LPA observed staff immediately relocate three (3) cleaning agents from the unlocked cabinet in bathroom #1. LPA and Licensee have agreed that two (2) locks need to be replaced in bathroom one if staff are to continue storing cleaning agents under the sink in bathroom one.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Mario Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


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: TERRA VERDE LIVING LLC
FACILITY NUMBER: 198602193
VISIT DATE: 07/18/2025
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LPA reviewed (3) Medication Administration Records (MARs), no discrepancies were found.
LPA observed the facility remains under infection control practices, as the facility appears to be in a clean and working condition. Staff have documented all six (6) residents AM and PM body temperatures. All mandated inspection control posters were posted throughout the facility and a copy of liability insurance, valid through 09/04/25, was provided to LPA during today's visit. LPA also verified this facilities' Annual Fee(s) as being current.
According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed two (2) deficiencies. Please see LIC809-D.

An exit interview was held with staff one, Tina Cinco - Licensee (S1), and a copy of two (2) deficiencies cited, facilities' appeal rights and this Facility Evaluation Report was provided to staff one, Tina Cinco (S1) - Licensee.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
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