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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602983
Report Date: 11/02/2024
Date Signed: 11/02/2024 11:19:11 AM

Document Has Been Signed on 11/02/2024 11:19 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:TARRASAFACILITY NUMBER:
198602983
ADMINISTRATOR/
DIRECTOR:		MATT PALMERFACILITY TYPE:
740
ADDRESS:27612 TARRASA DRTELEPHONE:
(424) 267-6267
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 5DATE:
11/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:37 AM
MET WITH:Administrator Matthew PalmerTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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On 11/02/2024, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with the House Manager. The Administrator Matthew Palmer joined us later. The facility is licensed for (6) non-ambulatory of which (1) maybe bedridden for ages 60 and above. It is also licensed for (6) hospice residents. Currently, there are (2) residents on hospice and (1) bedridden resident.

Facility is a one-story family home with (6) bedrooms, (2) full bathrooms, (½) half bathroom, living room, dining room, office area, closet/storage space located in the hallway, kitchen, patio, and backyard. A one (1) car attached garage is located on the front of the property. Front yard landscape is in good condition at time of visit. There is one wheelchair ramp on the left front side of the house that connects to the back-left side of the backyard. There is one located on the center patio deck across from the living room. One located center back against the home, and one located to the right-hand side of the kitchen and dining room. Washer/Dryer appliances are located in the garage. The facility is clean, sanitary, and in good repair.

The House Manager accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TARRASA
FACILITY NUMBER: 198602983
VISIT DATE: 11/02/2024
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Resident bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured between 108-degree F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked kitchen cabinet. First Aid kit was available. One fire extinguisher, last serviced October 4, 2023 was observed across from the kitchen area. House Manager tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional and interconnected.

Five staff records were reviewed and 5 out of 5 staff records had required criminal record clearances or criminal record exemptions.

Five resident records were reviewed and 5 out of 5 resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed.

No deficiencies are being cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with the Administrator Matthew Palmer.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC809 (FAS) - (06/04)
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