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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201002
Report Date: 02/20/2025
Date Signed: 02/20/2025 06:18:25 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231101141757
FACILITY NAME:TUSCANY VILLA SENIOR LIVINGFACILITY NUMBER:
019201002
ADMINISTRATOR:GOMBIO, JANICEFACILITY TYPE:
740
ADDRESS:790 HOLMES STREETTELEPHONE:
(925) 371-3090
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:31CENSUS: 25DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Janice Gombio, Executive Director
Isabel Poderoso, Campus Director		TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care due to lack of supervision
Facility is short staff
INVESTIGATION FINDINGS:
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On 2/20/2025 at 11:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegations above. LPA met with Executive Director, Janice Gombio and informed her the reason for visit.

During the investigation, LPA interviewed 1 resident, 4 staff, 2 witnesses, and complainant. LPA reviewed and obtained documents including staff roster with contact information, staff schedule, physician's report, care plan, hospice records, medical record, emergency information, care notes, and shower notes.

Resident sustained unexplained injuries while in care due to lack of supervision
Hospice records dated 10/11/2023 indicated that R2 had bruises. R2 was admitted to the facility on 10/17/2023 and facility notes revealed that R2 had bruises during admission. Interview with staff revealed that R2 had an unwitnessed fall on 11/6/2023. Facility incident report indicated that R2 was found in a sitting position on the floor and a bump was observed on the top of R2's head. (continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 2
Control Number 15-AS-20231101141757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TUSCANY VILLA SENIOR LIVING
FACILITY NUMBER: 019201002
VISIT DATE: 02/20/2025
NARRATIVE
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Staff stated that residents are check on every 2-4 hours and some residents are check on more often.

Facility is short staff
Interview with resident indicated there are enough staff working at the facility. R1 stated when R1 had a fall, staff was there to help right away. Interview with staff revealed that there are 2 caregivers and 1 med tech working during the AM and PM shift, and 1 caregiver and 1 med tech working NOC shift. Majority of the staff stated there are enough staff to meet the needs of the residents. S1 stated even during a COVID outbreak, facility was still able to maintain the same amount of staff on the different shifts. LPA observed there were a total of 7 staff (2 house keepers, 1 med tech, 2 caregivers, activity coordinator, and administrator) present during visit on 11/8/2023.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2