<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601160
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:59:50 PM

Document Has Been Signed on 11/27/2023 03:59 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
SAN BRUNO RO, 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:
11/27/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Stephanie VeridianoTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/27/23 LPA Grace Donato made an unannounced pre-licensing visit to the facility. LPA met with Program Coordinator Rommel Dionson, Administrator Stephanie Veridiano & Co-Administrator Rosemarie Veridiano. 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. 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.

Resident records are updated, complete and signed. Staff records are complete, with training logs.

Component III is conducted on this day.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1