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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201002
Report Date: 02/18/2022
Date Signed: 02/18/2022 04:32:15 PM


Document Has Been Signed on 02/18/2022 04:32 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
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:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Janice Gombio, Administrator
Isabel Poderoso, Campus Director		TIME COMPLETED:
04:45 PM
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On 2/18/2022 at 2:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Janice Gombio and Campus Director, Isabel Poderoso.

Upon entry, staff did not conduct COVID-19 screening for LPA. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, hand washing stations, kitchen, and common areas. LPA observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All sinks and bathrooms were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed staff were fit tested and COVID-19 test results were available. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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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