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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201002
Report Date: 01/26/2024
Date Signed: 01/26/2024 07:20:17 PM


Document Has Been Signed on 01/26/2024 07:20 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: 23DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Janice Gombio, Administrator
Isabel Poderoso, Campus Director		TIME COMPLETED:
07:30 PM
NARRATIVE
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On 1/26/2024 at 10:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Janice Gombio and Campus Director, Isabel Poderoso. The facility’s fire clearance was approved for 31 non-ambulatory residents of which 12 residents may be under hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Freezer’s temperature was registered at 0 degree F while the refrigerator’s temperature was recorded at 40 degrees F. Hot water temperature was measured at 115.7 degrees F in a resident's bathroom. Grab bars and non-skid mats were observed. There were adequate lights in each room. Centrally stored medications were locked in medication cart. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 1/4/2024. Indoor and outdoor passages were free of obstruction.

LPA reviewed 5 residents and 5 staff files starting at 1:10PM. LPA interviewed 3 residents starting at 12:00PM. LPA reviewed a sample of resident's medications starting at 5:20PM. LPA interviewed 3 staff starting at 5:50PM.

At 2:00PM, LPA observed R1 and R2 does not have current medical assessments and R2 does not have current reappraisal needs and service plans on file.

At 3:30PM, LPA observed S4 does not have health screening on file.

(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


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
VISIT DATE: 01/26/2024
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At 5:40PM, LPA observed R2 ran out of medications (Primidone 250mg and Donepezil HCI 5mg). LPA was informed that R2 have not taken Donepezil for a few days. Staff stated that medications were ordered last week.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/26/2024 07:20 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: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having health screening documents for S4 which poses a potential health and safety risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator has agreed to obtain health screening for S4 and submit a copy of health screening to CCLD by POC date.

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: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 01/26/2024 07:20 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: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having R2's prescribed medications available which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/29/2024
Plan of Correction
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Administrator has agreed to notify R2's doctor regarding missed medications. Administrator will request for refills for the two medications again and submit document proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 01/26/2024 07:20 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: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current medical assessments and reappraisals for resident(s) which poses a potential health and safety risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator has agreed to obtain current medical assessment for R1 and R2 and current reappraisal for R2. Administrator will submit copies to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6