198602983-8-30-2022-11-AS-ASOO-CHQRW8-20220828132242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602983
Report Date: 08/28/2022
Date Signed: 08/30/2022 10:17:44 AM

Document Has Been Signed on 08/30/2022 10:17 AM - 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:	TARRASA		FACILITY NUMBER:	198602983
ADMINISTRATOR:	MATT PALMER		FACILITY TYPE:	740
ADDRESS:	27612 TARRASA DR		TELEPHONE:	(424) 267-6267
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY: 6		CENSUS: 5	DATE:	08/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Lisa Sergio, Care giver		TIME COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met with Lisa Sergio, Care giver and later spoke and met with Matt Palmer, Administrator and the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (0) residents are ambulatory, (5) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (6) bedrooms, (2) full bathrooms, 1/2 bathroom, egress system in all exit doors, The facility has ramps along the outside 4 walls of the facility, shaded back yard, side patio, front yard, laundry room and attached 2 garage.

LPA and Lisa toured the entire facility inside and out. The facility converted part of garage for staff quarters, (Per administrator room already existed when the facility was bought. It is not part of the facility sketch, administrator to send copy of permits.) Bedrooms 1-5 are occupied by residents and contain the mandated furniture. Bedroom 6 is a staff bedroom. The (2) bathrooms are clean and operational. 1/2 bathroom is a staff bathroom. 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 1 water fountain outside of side patio, which does not pose a hazard for residents. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is 105.3) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TARRASA	FACILITY NUMBER: 198602983
	VISIT DATE: 08/28/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & Crome book for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days.Staff and Resident are fully vaccinated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. See 809D

Technical Advisory (TA) issued:

1. No fit testing completed for staff.

An exit interview conducted with Matt Palmer, Administrator and a hard copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2022 10:17 AM - It Cannot Be Edited

Created By: Ana Soto On 08/28/2022 at 11:38 AM

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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TARRASA	FACILITY NUMBER: 198602983
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87305(a) Prior to construction or alterations, all facilities shall obtain a building permit. This was not met as evidence by: Based on The facility converted part of garage for staff quarters, (Per licensee room already existed when the facility was bought. It is not part of the facility sketch, Licensee to send copy of permits.) Which potentially pose a health and safety risk for all person in care.
	POC Due Date: 09/28/2022
	Plan of Correction
1 2 3 4	Licensee to send copy of permits to LPA on or before POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Janae Hammond

LICENSING EVALUATOR NAME:

Ana Soto

LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2022

LIC809 (FAS) - (06/04)

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