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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601160
Report Date: 10/23/2023
Date Signed: 10/23/2023 11:54:08 AM

Document Has Been Signed on 10/23/2023 11:54 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:TARA MANOR INC.FACILITY NUMBER:
415601160
ADMINISTRATOR:VERIDIANO, STEPHANIEFACILITY TYPE:
740
ADDRESS:2545 TARA LANETELEPHONE:
(650) 892-1339
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 6DATE:
10/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Rommel Dionson & Stephanie Veridiano TIME COMPLETED:
12:10 PM
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On 10/23/23 LPA Grace Donato made an unannounced pre-licensing visit to the facility. LPA met with Caregiver Maria Badiola and Program Coordinator Rommel Dionson & Administrator Stephanie Veridiano followed after. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No residents currently in the facility due to residents being in day programs. LPA observed paint buckets & slabs of wood covered with tarp since facility is being repainted and repaired. Facility will clean up in 2 weeks after all the work is finished. The residents have adequate amount of linens and all personal belongings are intact. While touring the facility it was observed that the room temperature was at 71 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. Client bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable.

Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Three client records and three staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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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