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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201002
Report Date: 12/02/2022
Date Signed: 12/02/2022 04:32:59 PM


Document Has Been Signed on 12/02/2022 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:GOMBIO, JANICEFACILITY TYPE:
740
ADDRESS:790 HOLMES STREETTELEPHONE:
(925) 371-3090
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:31CENSUS: 19DATE:
12/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Janice Gombio, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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On 12/2/2022 at 1:40PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 11/25/2022. LPA met with Administrator, Janice Gombio.

Incident report dated 11/24/2022 revealed that R1 AWOL and set off front door alarm with delayed egress. Law enforcement was able to locate R1 and was transferred to hospital for evaluation.

Interview with staff revealed that R1 left the facility while S2 was with another resident. There was only one night staff at the time of incident. When S1 arrived to the facility at around 1:30am, the front door alarm was on and staff called 911. Police was able to locate R1 at a nearby grocery store and was sent to hospital.

During record review, LPA observed that physician's report dated 8/9/2022 stated that R1 cannot leave the facility unassisted.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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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Document Has Been Signed on 12/02/2022 04:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2022
Section Cited

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Care of Persons with Dementia. There is an adequate number of direct care staff to support each resident’s physical,...safety and health care needs... This requirement is not met as evidence by:
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Based on interview, licensee did not comply with the section cited above by not having adequate number of staff and resulting in a resident leaving the facility which poses an immediate health and safety risk to the 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
LIC809 (FAS) - (06/04)
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