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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201002
Report Date: 01/11/2021
Date Signed: 01/11/2021 04:31:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 LIVINGFACILITY NUMBER:
019201002
ADMINISTRATOR:AGCAOILI, MARIAFACILITY TYPE:
740
ADDRESS:790 HOLMES STREETTELEPHONE:
(925) 371-3090
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:31CENSUS: 21DATE:
01/11/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Toby Tilford, Licensee
Isabel Poderosa, Campus Director
Janice Gombio, Administrator
Maria Acaoili, Former Administrator
TIME COMPLETED:
04:00 PM
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On 1/11/2021 at 2:30PM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit Pre-Licensing inspection via Zoom due to shelter in place directed by the Governor. LPA spoke with Toby Tilford (Licensee), Isabel Poderosa (Campus Director), Janice Gombio (Administrator), and Maria Agcaoili (Former Administrator). The facility's fire clearance was approved for 31 non-ambulatory residents.

During the Tele-Inspection, LPA toured facility with Administrators and Campus Director including but not limited to resident's bedrooms, bathrooms, common areas, kitchen, laundry room, activity room and outdoor area. Resident's bedrooms are fully furnished with bed, dresser, night stand, and chair. Resident's bathrooms were equipped with grab bars and showers have non-skid mats. LPA observed lighting in all rooms. LPA observed facility had a 7-day of non-perishable and 2-day perishable food supplies. Facility has a medication cart located in the med room which was locked during inspection. Smoke detectors are interconnected with sprinkler system. Carbon Monoxide detectors were observed in common areas. First aid kit is complete. Facility staff had check the hot water temperature this morning which was 109.6 degrees F. LPA advised Administrator that hot water temperature should be maintained between 105 degrees F and 120 degrees F. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full and last serviced on 4/1/2020. Emergency disaster plan was completed on 5/20/2020.

LPA conducted Component III with Administrators and Campus Director during Tele-visit. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. Exit interview conducted and a copy of this report will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2021
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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