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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601160
Report Date: 12/17/2025
Date Signed: 12/17/2025 11:01:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2025 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250210113400
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:
12/17/2025
UNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Rose Veridiano & Rommel DionsonTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident sustained a fracture while in care
INVESTIGATION FINDINGS:
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On 12/17/2025 , LPA Grace Donato conducted a complaint investigation visit to deliver findings. LPA met with Rose Veridiano & Rommel Dionson and explained the purpose of the visit.

Regarding the allegation of Resident (R1) sustained a fracture while in care, On 1/18/2025, R1 was sent to the hospital due to a swollen left thigh.

During the investigation, staff members were interviewed, and records were reviewed.

Based on Day Program staff interviews and documents, R1 attended regular program on 01/17/2025 and returned to facility. Staff recalled R1 being at baseline. Staff perform two “full-body checks” on all their incontinent clients to ensure the client does not have any injuries, rashes, or abnormalities before the client returns home. Staff recalled R1’s left leg to be intact without any signs of injury or discomfort.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 14-AS-20250210113400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/17/2025
NARRATIVE
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Based on facility notes, R1 did not have any falls, injuries, or redness until 01/18/2025. On 01/18/2025, it notes thigh is swelling and looked weightless after moving while changing.

Based on staff statements and facility documents, R1 was last seen in normal physical condition on 01/18/2025, at around 9am, and was found by S1 with a left thigh injury between 1100-1150pm. Staff denied R1 falling out of bed or having an accident while using the Hoyer lift. Staff denied R1 hitting his/her leg against the bed or another resident assaulting R1. Staff denied assaulting R1 and staff did not know how R1 sustained the injury.

Based on the findings, R1 sustained an unexplained femur fracture while in care at the facility.

At the time of the complaint inspection on 12/17/2025 licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code §1569.49.

Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC-9099D.

An immediate $500.00 was assessed today due to R1 sustaining unexplained injury while in care.

Report is reviewed and a copy of the report and Appeal Rights is provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC9099 (FAS) - (06/04)
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Control Number 14-AS-20250210113400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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Licensee to do an in-service training about care and supervision of residents, postural supports and mandatory reporting. Licensee to submit by POC due date.
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This was not met as evidenced by:
Based on interviews and records review, R1 sustained an unexplained injury while in care which poses an immediate Health, Safety, or Personal Rights risk to persons 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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
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