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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601160
Report Date: 10/30/2025
Date Signed: 10/30/2025 01:47:19 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/30/2025 01:47 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:
10/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Joselito Delazo, Rommel DionsonTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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LPA Jeung toured facility and grounds, including two detached storage sheds. This is a 2-story building; staff occupy the 2nd floor and clients reside on the ground level, where there are 2 shared and 2 private client bedrooms, two kitchens, living and dining rooms, foyer, and two full bathrooms. On the upper level, there are large open spaces for living and family rooms, full kitchen, 3 bedrooms for staff--one room has 2 beds, another room has one bed for one staff, and the master bedroom has one bed for 2 staff, with an adjacent full bathroom--and second full bathroom. There is no garage. Washer and dryer are located on ground level utility room. Wooden ramp in the backyard accesses 2nd floor. No residents are present.
No accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, and a comfortable temperature is maintained. Bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature is tested in clients' bathroom at 107 degrees. Food supply and first-aid kits are inspected. An Emergency Disaster Plan is posted.

Client files are reviewed, including clients' Centrally Stored Medication Records. All clients are ambulatory, and all but one are under age 60.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Stephanie Veridiano and Rommel Dionson are certified RCFE administrators (x 4/27 & 5/27) that oversee facility operations.

Continued on following page.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TARA MANOR INC.
FACILITY NUMBER: 415601160
VISIT DATE: 10/30/2025
NARRATIVE
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The following forms are requested to be updated and returned to CCL by 11/13/25:
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• Corrected facility sketch/floor plan for ground floor

The following updated information is provided to LPA today:
- proof of current surety bonding
- proof of current liability insurance

Deficiencies of the RCFE California Code of Regulations, Title 22, are observed and cited on a following page. See also Technical Advisory Note--one page.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2025 01:47 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/30/2025 at 01:26 PM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TARA MANOR INC.
FACILITY NUMBER: 415601160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2025
Section Cited
CCR
87355(e)(2)

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to HSC 1569.17(b) shall prior to working, residing or volunteering in a licensed facility obtain a CA clearance or a criminal record exemption as required by the Dept.
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Criminal record clearance for staff #6 was reassociated to facility in LPA's presence.
Deficiency corrected and cleared.
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This requirement was not met, as criminal record clearance for staff #6 is not associated to facility. Licensee failed to ensure that criminal record clearance for S6 was reinstated when he resumed work at facility, which posed an immediate health, safety or personal rights risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2025 01:47 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/30/2025 at 01:32 PM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TARA MANOR INC.
FACILITY NUMBER: 415601160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2025
Section Cited
CCR
87309(a)

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STORAGE SPACE
... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances..., and other similar items which could pose a danger to residents are in locked storage...
This requirement is not met, as several paint cans are stored in unlocked storage shed in
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Detached storage shed will be locked so paint is not accessible to clients.
Proof of correction to be sent to CCLD BY DUE DATE
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backyard. Licensee failed to ensure that paint is inaccessible to clients, which poses a potential health, safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2025


LIC809 (FAS) - (06/04)
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