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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601160
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:55:13 PM

Document Has Been Signed on 01/23/2025 04:55 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/
DIRECTOR:		VERIDIANO, STEPHANIEFACILITY TYPE:
740
ADDRESS:2545 TARA LANETELEPHONE:
(650) 892-1339
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 5DATE:
01/23/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Stephanie Veridiano & Rommel DionsonTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 1/23/2025, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning an incident report received. LPA met with Administrator Stephanie Veridiano & Co-Administrator Rommel Dionson. LPA explained the purpose of today's visit.

On 1/21/2025, LPA received an incident report regarding a resident (R1) having moderate swelling on the upper leg with slight green discoloration on the left inner upper leg. R1 was then transferred to Zuckerberg San Francisco General Hospital & Trauma Center.

Facility reported the incident to Police and APS but was told that since there is no perpetrator they are not able to start an investigation.

LPA interviewed staff. S1 said that R1 had a change in diaper at around 6am, diaper was removed at 8am and R1 had a pad on the bed. Through the diaper changes there was no swelling observed up until 11am.

Based also on records review, there is no observation of resident having swelling from when R1 arrived from day program the day before.

R1 has had an old fracture of distal & femoral shaft.

No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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